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Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage With Cc","code_information":[{"code":"378","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7353.2,"maximum":11683.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11683.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7353.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11278.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7353.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11179.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7353.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9114.63},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8862.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1882.0,"10th_percentile":1882.0,"90th_percentile":1882.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Hemorrhage Without Cc/Mcc","code_information":[{"code":"379","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4892.53,"maximum":7509.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7509.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4892.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7249.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4892.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7186.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4892.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5858.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5696.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Mcc","code_information":[{"code":"380","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14247.7,"maximum":23375.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23375.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14247.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22565.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14247.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22369.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14247.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18236.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17732.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer With Cc","code_information":[{"code":"381","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8075.31,"maximum":12907.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12907.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8075.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12460.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8075.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12351.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8075.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10070.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9791.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complicated Peptic Ulcer Without Cc/Mcc","code_information":[{"code":"382","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6088.1,"maximum":9537.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9537.55},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6088.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9206.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6088.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9126.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6088.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7440.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7235.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer With Mcc","code_information":[{"code":"383","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10162.98,"maximum":16448.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16448.28},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10162.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15878.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10162.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15739.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10162.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12832.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12477.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uncomplicated Peptic Ulcer Without Mcc","code_information":[{"code":"384","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6468.82,"maximum":10183.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10183.23},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6468.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9830.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6468.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9744.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6468.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7944.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7724.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Mcc","code_information":[{"code":"385","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11579.11,"maximum":18849.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18849.94},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11579.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18196.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11579.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18038.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11579.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14705.9},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14299.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease With Cc","code_information":[{"code":"386","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7322.29,"maximum":11630.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11630.66},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7322.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11227.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7322.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11129.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7322.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9073.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8822.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammatory Bowel Disease Without Cc/Mcc","code_information":[{"code":"387","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5250.08,"maximum":8116.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8116.33},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5250.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7834.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5250.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7766.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5250.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6332.0},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6156.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":7036.14,"10th_percentile":7036.14,"90th_percentile":7036.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Mcc","code_information":[{"code":"388","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10838.03,"maximum":17593.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17593.12},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10838.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16983.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10838.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16835.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10838.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13725.38},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13345.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7032.79,"10th_percentile":7032.79,"90th_percentile":7032.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction With Cc","code_information":[{"code":"389","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6012.23,"maximum":9408.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9408.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6012.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9082.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6012.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9003.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6012.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7340.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7137.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":11239.75,"10th_percentile":11239.75,"90th_percentile":11239.75,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Gastrointestinal Obstruction Without Cc/Mcc","code_information":[{"code":"390","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4285.62,"maximum":6480.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6480.67},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4285.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6256.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4285.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6201.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4285.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5055.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4916.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders With Mcc","code_information":[{"code":"391","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9373.43,"maximum":15109.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15109.26},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9373.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14585.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9373.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14458.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9373.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11787.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11461.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5553.61,"10th_percentile":5553.61,"90th_percentile":5553.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Esophagitis, Gastroenteritis And Miscellaneous Digestive Disorders Without Mcc","code_information":[{"code":"392","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5940.58,"maximum":9287.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9287.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5940.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8965.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5940.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8887.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5940.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7245.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7045.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":12299.18,"10th_percentile":12299.18,"90th_percentile":12299.18,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5842.71,"10th_percentile":5842.71,"90th_percentile":5842.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":8190.81,"10th_percentile":8190.81,"90th_percentile":8190.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Mcc","code_information":[{"code":"393","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11698.53,"maximum":19052.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19052.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11698.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18391.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11698.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18232.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11698.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14863.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14452.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":13708.83,"10th_percentile":13708.83,"90th_percentile":13708.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses With Cc","code_information":[{"code":"394","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7037.1,"maximum":11146.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11146.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7037.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10760.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7037.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10666.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7037.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8696.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8455.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections Without Cc/Mcc","code_information":[{"code":"373","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5573.91,"maximum":8665.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8665.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5573.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8365.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5573.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8292.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5573.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6760.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6573.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Cc","code_information":[{"code":"372","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7636.29,"maximum":12163.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12163.17},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7636.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11741.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7636.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11639.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7636.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9489.17},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9226.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":17948.21,"10th_percentile":17948.21,"90th_percentile":17948.21,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Gastrointestinal Disorders And Peritoneal Infections With Mcc","code_information":[{"code":"371","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12919.38,"maximum":21122.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21122.94},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12919.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20390.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12919.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20213.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12919.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16479.19},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16023.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":1801.54,"10th_percentile":1801.54,"90th_percentile":1801.54,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders Without Cc/Mcc","code_information":[{"code":"370","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5387.06,"maximum":8348.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8348.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5387.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8059.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5387.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7989.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5387.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6513.24},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6333.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Cc","code_information":[{"code":"369","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7490.18,"maximum":11915.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11915.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11502.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11402.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7490.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9295.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9038.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Esophageal Disorders With Mcc","code_information":[{"code":"368","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11646.54,"maximum":18964.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18964.3},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18306.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18147.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11646.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14795.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14386.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device Without Mcc","code_information":[{"code":"360","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17423.45,"maximum":28761.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28761.56},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17423.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27764.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17423.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27523.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17423.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22438.5},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21818.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy With Intraluminal Device With Mcc","code_information":[{"code":"359","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24618.6,"maximum":40964.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40964.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24618.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39543.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24618.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39200.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24618.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31958.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31074.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"358","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10283.8,"maximum":16653.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16653.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10283.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16075.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10283.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15936.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10283.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12992.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12632.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Cc","code_information":[{"code":"351","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11173.1,"maximum":18161.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18161.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11173.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17531.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11173.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17379.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11173.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14168.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13776.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12461.99,"10th_percentile":12461.99,"90th_percentile":12461.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal And Femoral Hernia Procedures With Mcc","code_information":[{"code":"350","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17968.55,"maximum":29686.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29686.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17968.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28656.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17968.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28407.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17968.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23159.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22519.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures Without Cc/Mcc","code_information":[{"code":"349","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6579.81,"maximum":10371.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10371.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6579.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10011.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6579.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9924.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6579.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8091.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7867.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Cc","code_information":[{"code":"348","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9657.92,"maximum":15591.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15591.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9657.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15051.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9657.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14920.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9657.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12163.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11827.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Anal And Stomal Procedures With Mcc","code_information":[{"code":"347","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16589.65,"maximum":27347.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27347.48},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26399.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26169.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16589.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21335.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20745.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"346","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8796.72,"maximum":14131.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14131.2},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8796.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13641.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8796.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13522.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8796.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11024.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10719.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8663.07,"10th_percentile":8663.07,"90th_percentile":8663.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Cc","code_information":[{"code":"345","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11034.01,"maximum":17925.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17925.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11034.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17304.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11034.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17153.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11034.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13984.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13597.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Small And Large Bowel Procedures With Mcc","code_information":[{"code":"344","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18607.07,"maximum":30768.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30768.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18607.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29702.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18607.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29443.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18607.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24004.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23340.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis Without Cc/Mcc","code_information":[{"code":"337","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11246.85,"maximum":18286.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18286.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11246.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17652.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11246.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17499.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11246.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14266.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13871.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Cc","code_information":[{"code":"336","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15276.78,"maximum":25120.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25120.94},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15276.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24250.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15276.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24039.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15276.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19598.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19056.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peritoneal Adhesiolysis With Mcc","code_information":[{"code":"335","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25547.93,"maximum":42540.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42540.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25547.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41065.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25547.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40708.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25547.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33187.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32270.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection Without Cc/Mcc","code_information":[{"code":"334","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11969.67,"maximum":19512.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19512.3},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11969.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18835.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11969.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18672.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11969.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15222.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14801.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Cc","code_information":[{"code":"333","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16916.99,"maximum":27902.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27902.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16916.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26935.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16916.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26701.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16916.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21768.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21166.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rectal Resection With Mcc","code_information":[{"code":"332","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25897.75,"maximum":43133.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43133.4},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25897.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41638.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25897.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41275.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25897.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33650.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32720.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures Without Cc/Mcc","code_information":[{"code":"331","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12285.77,"maximum":20048.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20048.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12285.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19353.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12285.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19185.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12285.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15640.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15208.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small And Large Bowel Procedures With Cc","code_information":[{"code":"330","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17303.34,"maximum":28557.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28557.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17303.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27567.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17303.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27328.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17303.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22279.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21663.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":44668.32,"10th_percentile":44668.32,"90th_percentile":44668.32,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":13482.81,"10th_percentile":13482.81,"90th_percentile":13482.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Major Small And Large Bowel Procedures With Mcc","code_information":[{"code":"329","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32752.21,"maximum":54758.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54758.1},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32752.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52859.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32752.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52400.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32752.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42719.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41538.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1650.0,"10th_percentile":1650.0,"90th_percentile":1650.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures Without Cc/Mcc","code_information":[{"code":"328","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11719.6,"maximum":19088.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19088.2},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11719.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18426.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11719.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18266.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11719.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14891.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14479.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Cc","code_information":[{"code":"327","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17633.48,"maximum":29117.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29117.75},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17633.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28108.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17633.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27863.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17633.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22716.39},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22088.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal And Duodenal Procedures With Mcc","code_information":[{"code":"326","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35498.07,"maximum":59414.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59414.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35498.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57355.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35498.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56856.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35498.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46352.9},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45071.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy Without Intraluminal Device","code_information":[{"code":"325","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23015.62,"maximum":38245.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38245.5},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23015.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36919.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23015.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36598.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23015.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29837.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29012.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device Without Mcc","code_information":[{"code":"324","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22598.37,"maximum":37537.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37537.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22598.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36236.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22598.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35921.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22598.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29285.39},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28475.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Intravascular Lithotripsy With Intraluminal Device With Mcc","code_information":[{"code":"323","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30861.93,"maximum":51552.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51552.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30861.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49765.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30861.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49332.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30861.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40218.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39106.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device Without Mcc","code_information":[{"code":"322","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12848.43,"maximum":21002.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21002.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12848.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20274.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12848.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20098.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12848.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16385.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15932.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":68185.74,"10th_percentile":68185.74,"90th_percentile":68185.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14957.26,"10th_percentile":14957.26,"90th_percentile":14957.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Intraluminal Device With Mcc Or 4+ Arteries/Intraluminal","code_information":[{"code":"321","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19576.45,"maximum":32412.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32412.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19576.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31289.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19576.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31017.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19576.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25287.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24587.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":825.0,"10th_percentile":825.0,"90th_percentile":825.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":29882.86,"10th_percentile":29882.86,"90th_percentile":29882.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures Without Mcc","code_information":[{"code":"320","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17360.23,"maximum":28654.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28654.34},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17360.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27660.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17360.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27420.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17360.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22354.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21736.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endovascular Cardiac Valve Procedures With Mcc","code_information":[{"code":"319","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31813.75,"maximum":53166.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53166.53},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31813.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51323.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31813.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50877.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31813.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41478.19},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40331.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Coronary Atherectomy Without Intraluminal Device","code_information":[{"code":"318","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17478.95,"maximum":28855.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28855.67},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17478.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27855.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17478.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27613.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17478.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22511.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21889.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Left Atrial Appendage Closure And Cardiac Ablation","code_information":[{"code":"317","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47433.32,"maximum":79656.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79656.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47433.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76894.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47433.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76226.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47433.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62144.33},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60425.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses Without Cc/Mcc","code_information":[{"code":"316","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5255.7,"maximum":8125.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8125.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5255.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7844.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5255.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7775.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5255.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6339.44},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6164.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Cc","code_information":[{"code":"315","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7230.97,"maximum":11475.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11475.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7230.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11077.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7230.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10981.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7230.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8952.91},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8705.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":10101.26,"10th_percentile":10101.26,"90th_percentile":10101.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System Diagnoses With Mcc","code_information":[{"code":"314","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15111.71,"maximum":24840.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24840.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15111.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23979.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15111.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23771.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15111.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19379.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18843.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chest Pain","code_information":[{"code":"313","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5521.93,"maximum":8577.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8577.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5521.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8280.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5521.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8208.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5521.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6691.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6506.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":5224.0,"10th_percentile":5224.0,"90th_percentile":5224.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Syncope And Collapse","code_information":[{"code":"312","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6586.83,"maximum":10383.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10383.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6586.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10023.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6586.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9936.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6586.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8100.65},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7876.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2513.71,"10th_percentile":2513.71,"90th_percentile":2513.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Angina Pectoris","code_information":[{"code":"311","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5394.78,"maximum":8361.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8361.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5394.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8071.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5394.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8001.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5394.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6523.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6343.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders Without Cc/Mcc","code_information":[{"code":"310","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4440.86,"maximum":6743.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6743.95},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4440.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6510.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4440.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6453.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4440.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5261.33},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5115.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"1 through 10","median_amount":207.44,"10th_percentile":207.44,"90th_percentile":207.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4370.33,"10th_percentile":4370.33,"90th_percentile":4370.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":5873.07,"10th_percentile":5873.07,"90th_percentile":5942.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":63.19,"10th_percentile":63.19,"90th_percentile":63.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Cc","code_information":[{"code":"309","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5632.21,"maximum":8764.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8764.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5632.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8460.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5632.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8386.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5632.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6837.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6648.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":11831.01,"10th_percentile":11831.01,"90th_percentile":11831.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5549.84,"10th_percentile":5549.84,"90th_percentile":5549.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4170.02,"10th_percentile":4170.02,"90th_percentile":5955.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.38,"10th_percentile":81.38,"90th_percentile":81.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Cardiac Arrhythmia And Conduction Disorders With Mcc","code_information":[{"code":"308","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8921.76,"maximum":14343.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14343.25},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8921.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13846.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8921.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13725.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8921.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11189.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10880.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1676.0,"10th_percentile":1676.0,"90th_percentile":1676.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":4405.43,"10th_percentile":4405.43,"90th_percentile":4405.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":81.38,"10th_percentile":81.38,"90th_percentile":81.38,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Cardiac Congenital And Valvular Disorders Without Mcc","code_information":[{"code":"307","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6879.05,"maximum":10878.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10878.95},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6879.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10501.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6879.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10410.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6879.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8487.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8252.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Congenital And Valvular Disorders With Mcc","code_information":[{"code":"306","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11533.45,"maximum":18772.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18772.51},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11533.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18121.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11533.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17964.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11533.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14645.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14240.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension Without Mcc","code_information":[{"code":"305","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5768.48,"maximum":8995.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8995.51},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5768.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8683.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5768.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8608.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5768.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7017.9},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6823.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertension With Mcc","code_information":[{"code":"304","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8823.42,"maximum":14176.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14176.47},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8823.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13685.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8823.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13566.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8823.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11059.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10754.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis Without Mcc","code_information":[{"code":"303","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5193.18,"maximum":8019.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8019.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5193.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7741.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5193.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7674.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5193.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6256.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6083.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Atherosclerosis With Mcc","code_information":[{"code":"302","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8869.78,"maximum":14255.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14255.1},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8869.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13760.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8869.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13641.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8869.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11121.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10813.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders Without Cc/Mcc","code_information":[{"code":"301","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5519.82,"maximum":8573.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8573.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8276.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8204.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5519.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6688.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6503.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Cc","code_information":[{"code":"271","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25445.38,"maximum":42366.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42366.2},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25445.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40897.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25445.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40541.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25445.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33052.25},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32138.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":740.0,"10th_percentile":740.0,"90th_percentile":740.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures With Mcc","code_information":[{"code":"270","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37527.43,"maximum":62856.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62856.56},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37527.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60677.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37527.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60149.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37527.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49037.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47681.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon Without Mcc","code_information":[{"code":"269","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30129.98,"maximum":50310.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50310.98},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30129.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48566.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30129.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48144.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30129.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39250.42},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38165.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aortic And Heart Assist Procedures Except Pulsation Balloon With Mcc","code_information":[{"code":"268","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":48777.8,"maximum":81936.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81936.42},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48777.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79095.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48777.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78408.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":48777.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63923.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62155.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures Without Mcc","code_information":[{"code":"267","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33906.33,"maximum":56715.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56715.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33906.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54749.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33906.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54273.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33906.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44246.88},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43023.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Cardiac Valve Replacement And Supplement Procedures With Mcc","code_information":[{"code":"266","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43512.97,"maximum":73007.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73007.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43512.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70476.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43512.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69863.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43512.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56957.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55382.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Lead Procedures","code_information":[{"code":"265","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25880.19,"maximum":43103.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43103.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25880.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41609.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25880.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41247.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25880.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33627.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32697.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Circulatory System O.R. Procedures","code_information":[{"code":"264","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23930.2,"maximum":39796.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39796.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23930.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38416.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23930.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38082.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23930.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31047.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30189.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vein Ligation And Stripping","code_information":[{"code":"263","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21940.88,"maximum":36422.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36422.81},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21940.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35160.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21940.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34854.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21940.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28415.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27629.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Revision Except Device Replacement Without Cc/Mcc","code_information":[{"code":"262","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11913.47,"maximum":19417.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19417.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11913.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18743.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11913.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18580.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11913.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15148.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14729.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Cc","code_information":[{"code":"256","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12391.14,"maximum":20227.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20227.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12391.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19525.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12391.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19356.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12391.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15780.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15343.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Upper Limb And Toe Amputation For Circulatory System Disorders With Mcc","code_information":[{"code":"255","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19412.08,"maximum":32134.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32134.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19412.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31020.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19412.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30750.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19412.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25069.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24376.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures Without Cc/Mcc","code_information":[{"code":"254","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12979.79,"maximum":21225.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21225.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12979.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20489.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12979.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20311.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12979.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16559.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16101.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Cc","code_information":[{"code":"253","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18696.99,"maximum":30921.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30921.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18696.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29849.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18696.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29589.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18696.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24123.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23456.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25158.45,"10th_percentile":25158.45,"90th_percentile":25158.45,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Vascular Procedures With Mcc","code_information":[{"code":"252","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24967.72,"maximum":41556.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41556.12},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24967.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40115.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24967.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39766.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24967.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32420.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31523.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device Without Mcc","code_information":[{"code":"251","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10962.36,"maximum":17803.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17803.98},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17186.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17037.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10962.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13889.88},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13505.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures Without Intraluminal Device With Mcc","code_information":[{"code":"250","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15795.19,"maximum":26000.12,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26000.12},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15795.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25098.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15795.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24880.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15795.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20284.16},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19723.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aicd Generator Procedures","code_information":[{"code":"245","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32512.68,"maximum":54351.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54351.87},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32512.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52467.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32512.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52011.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32512.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42402.95},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41230.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant Without Cc/Mcc","code_information":[{"code":"244","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13161.02,"maximum":21532.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21532.75},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13161.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20786.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13161.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20605.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13161.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16798.91},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16334.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Cc","code_information":[{"code":"243","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15432.72,"maximum":25385.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25385.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15432.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24505.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15432.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24292.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15432.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19804.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19256.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Permanent Cardiac Pacemaker Implant With Mcc","code_information":[{"code":"242","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22891.99,"maximum":38035.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38035.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36717.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36397.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22891.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29673.88},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28853.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe Without Cc/Mcc","code_information":[{"code":"241","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10188.97,"maximum":16492.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16492.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10188.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15920.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10188.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15782.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10188.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12866.61},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12510.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Cc","code_information":[{"code":"240","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20487.52,"maximum":33958.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33958.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20487.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32780.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20487.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32495.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20487.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26492.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25759.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Circulatory System Disorders Except Upper Limb And Toe With Mcc","code_information":[{"code":"239","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35036.56,"maximum":58632.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58632.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35036.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56599.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35036.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56107.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35036.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45742.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44477.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization Without Mcc","code_information":[{"code":"236","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29888.34,"maximum":49901.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49901.17},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29888.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48171.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29888.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47752.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29888.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38930.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37854.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass Without Cardiac Catheterization With Mcc","code_information":[{"code":"235","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":41688.02,"maximum":69912.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69912.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67488.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66902.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":41688.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54542.77},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53034.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation Without Mcc","code_information":[{"code":"234","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38836.79,"maximum":65077.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65077.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38836.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62821.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38836.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62274.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38836.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50770.33},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49366.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Cardiac Catheterization Or Open Ablation With Mcc","code_information":[{"code":"233","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":54167.66,"maximum":91077.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":91077.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54167.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87919.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54167.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":87155.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":54167.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71054.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69089.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca Without Mcc","code_information":[{"code":"232","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43050.76,"maximum":72223.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72223.75},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43050.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69719.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43050.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69113.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43050.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56345.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54787.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass With Ptca With Mcc","code_information":[{"code":"231","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59679.75,"maximum":100425.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100425.4},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59679.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96943.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59679.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96100.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59679.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78347.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76181.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures Without Mcc","code_information":[{"code":"229","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22587.83,"maximum":37519.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37519.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22587.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36219.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22587.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35904.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22587.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29271.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28462.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures With Mcc","code_information":[{"code":"228","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35217.09,"maximum":58938.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58938.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35217.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56895.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35217.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56400.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35217.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45981.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44709.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve And Other Major Cardiothoracic Procedures Without Cardiac Catheterization Without Cc/M","code_information":[{"code":"221","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35868.96,"maximum":60043.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60043.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35868.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57962.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35868.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57458.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35868.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46843.62},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45548.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Heart Assist System Implant","code_information":[{"code":"215","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":70406.79,"maximum":118617.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118617.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70406.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":114505.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70406.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":113509.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":70406.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":92540.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89981.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endovascular Abdominal Aorta With Iliac Branch Procedures","code_information":[{"code":"213","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40552.16,"maximum":67986.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67986.3},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40552.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65629.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40552.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65058.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40552.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53039.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51573.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concomitant Aortic And Mitral Valve Procedures","code_information":[{"code":"212","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":76848.91,"maximum":129543.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":129543.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76848.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125052.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76848.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":123964.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":76848.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":101063.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98269.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complex Aortic Arch Procedures","code_information":[{"code":"209","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":79972.68,"maximum":134840.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134840.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79972.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130166.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79972.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":129034.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":79972.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105196.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102288.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support <=96 Hours","code_information":[{"code":"208","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19772.43,"maximum":32745.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32745.26},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19772.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31610.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19772.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31335.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19772.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25546.42},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24840.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory System Diagnosis With Ventilator Support >96 Hours","code_information":[{"code":"207","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":45664.56,"maximum":76656.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76656.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45664.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73999.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45664.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73355.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":45664.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59804.1},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58150.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses Without Mcc","code_information":[{"code":"206","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7075.03,"maximum":11211.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11211.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7075.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10822.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7075.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10728.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7075.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8746.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8504.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System Diagnoses With Mcc","code_information":[{"code":"205","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13326.09,"maximum":21812.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21812.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13326.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21056.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13326.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20873.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13326.09,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17017.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16546.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Signs And Symptoms","code_information":[{"code":"204","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6135.86,"maximum":9618.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9618.56},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6135.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9285.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6135.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9204.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6135.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7503.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7296.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma Without Cc/Mcc","code_information":[{"code":"203","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5170.7,"maximum":7981.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7981.71},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5170.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7705.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5170.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7638.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5170.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6226.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6054.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bronchitis And Asthma With Cc/Mcc","code_information":[{"code":"202","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7286.47,"maximum":11569.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11569.91},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7286.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11168.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7286.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11071.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7286.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9026.33},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8776.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":4399.87,"10th_percentile":4399.87,"90th_percentile":4399.87,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7177.35,"10th_percentile":7177.35,"90th_percentile":7177.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax Without Cc/Mcc","code_information":[{"code":"201","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5487.51,"maximum":8518.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8518.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5487.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8223.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5487.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8152.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5487.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6646.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6462.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Cc","code_information":[{"code":"200","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8186.3,"maximum":13095.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13095.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8186.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12641.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8186.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12532.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8186.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10216.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9934.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pneumothorax With Mcc","code_information":[{"code":"199","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12856.16,"maximum":21015.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21015.72},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12856.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20287.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12856.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20110.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12856.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16395.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15942.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":12629.2,"10th_percentile":12629.2,"90th_percentile":12629.2,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":356.71,"10th_percentile":356.71,"90th_percentile":356.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease Without Cc/Mcc","code_information":[{"code":"198","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5495.23,"maximum":8532.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8532.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5495.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8236.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5495.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8164.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5495.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6656.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6472.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5830.29,"10th_percentile":5830.29,"90th_percentile":5830.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Cc","code_information":[{"code":"197","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7131.23,"maximum":11306.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11306.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10914.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10819.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7131.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8820.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8577.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Interstitial Lung Disease With Mcc","code_information":[{"code":"196","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13720.87,"maximum":22482.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22482.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21702.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21514.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13720.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17539.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17054.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy Without Cc/Mcc","code_information":[{"code":"195","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4879.19,"maximum":7487.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7487.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4879.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7227.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4879.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7164.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4879.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5841.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5679.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":8638.58,"10th_percentile":8638.58,"90th_percentile":8638.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Cc","code_information":[{"code":"194","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6125.33,"maximum":9600.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9600.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6125.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9267.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6125.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9187.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6125.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7490.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7282.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":11611.43,"10th_percentile":11611.43,"90th_percentile":11611.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6031.61,"10th_percentile":6031.61,"90th_percentile":6031.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6031.1,"10th_percentile":6031.1,"90th_percentile":6031.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simple Pneumonia And Pleurisy With Mcc","code_information":[{"code":"193","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9697.26,"maximum":15658.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15658.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9697.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15115.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9697.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14984.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9697.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12216.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11878.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9560.52,"10th_percentile":9560.52,"90th_percentile":9586.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9525.79,"10th_percentile":9525.79,"90th_percentile":10924.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease Without Cc/Mcc","code_information":[{"code":"192","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4974.02,"maximum":7648.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7648.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4974.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7383.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4974.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7318.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4974.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5966.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5801.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Cc","code_information":[{"code":"191","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6385.93,"maximum":10042.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10042.66},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6385.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9694.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6385.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9610.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6385.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7834.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7618.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chronic Obstructive Pulmonary Disease With Mcc","code_information":[{"code":"190","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8245.31,"maximum":13196.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13196.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12738.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12627.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8245.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10294.96},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10010.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9300.73,"10th_percentile":9300.73,"90th_percentile":9300.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9321.74,"10th_percentile":9321.74,"90th_percentile":9321.74,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Edema And Respiratory Failure","code_information":[{"code":"189","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9142.33,"maximum":14717.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14717.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9142.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14207.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9142.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14083.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9142.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11481.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11164.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":44600.35,"10th_percentile":44600.35,"90th_percentile":44600.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1475.0,"10th_percentile":1475.0,"90th_percentile":1475.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":572.53,"10th_percentile":572.53,"90th_percentile":572.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion Without Cc/Mcc","code_information":[{"code":"188","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5502.26,"maximum":8544.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8544.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5502.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8247.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5502.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8176.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5502.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6665.66},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6481.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Cc","code_information":[{"code":"187","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7412.21,"maximum":11783.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11783.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7412.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11374.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7412.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11275.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7412.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9192.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8938.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pleural Effusion With Mcc","code_information":[{"code":"186","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11411.93,"maximum":18566.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18566.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17922.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17766.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11411.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14484.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14084.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma Without Cc/Mcc","code_information":[{"code":"185","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5989.05,"maximum":9369.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9369.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5989.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9044.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5989.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8966.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5989.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7309.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7107.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Cc","code_information":[{"code":"184","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7939.04,"maximum":12676.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12676.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7939.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12237.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7939.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12130.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7939.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9889.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9616.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Trauma With Mcc","code_information":[{"code":"183","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11211.03,"maximum":18225.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18225.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11211.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17593.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11211.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17440.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11211.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14218.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13825.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms Without Cc/Mcc","code_information":[{"code":"182","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5759.35,"maximum":8980.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8980.02},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5759.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8668.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5759.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8593.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5759.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7005.82},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6812.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Cc","code_information":[{"code":"181","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7987.51,"maximum":12758.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12758.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7987.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12316.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7987.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12209.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7987.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9953.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9678.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Neoplasms With Mcc","code_information":[{"code":"180","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12869.5,"maximum":21038.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21038.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12869.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20309.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12869.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20132.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12869.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16413.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15959.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations Without Cc/Mcc","code_information":[{"code":"179","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5767.78,"maximum":8994.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8994.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5767.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8682.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5767.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8607.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5767.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7016.97},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6822.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Cc","code_information":[{"code":"178","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7320.18,"maximum":11627.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11627.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11224.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11126.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7320.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9070.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8820.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7190.47,"10th_percentile":7190.47,"90th_percentile":7190.47,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1853.71,"10th_percentile":1853.71,"90th_percentile":1853.71,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Respiratory Infections And Inflammations With Mcc","code_information":[{"code":"177","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11441.43,"maximum":18616.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18616.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11441.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17971.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11441.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17814.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11441.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14523.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14122.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7323.26,"10th_percentile":7323.26,"90th_percentile":7323.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11247.94,"10th_percentile":11247.94,"90th_percentile":11247.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism Without Mcc","code_information":[{"code":"176","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6119.0,"maximum":9589.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9589.97},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6119.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9257.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6119.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9177.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6119.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7481.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7274.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pulmonary Embolism With Mcc Or Acute Cor Pulmonale","code_information":[{"code":"175","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10113.11,"maximum":16363.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16363.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10113.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15796.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10113.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15659.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10113.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12766.24},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12413.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":19284.35,"10th_percentile":19284.35,"90th_percentile":19284.35,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"1 through 10","median_amount":22233.56,"10th_percentile":22233.56,"90th_percentile":22233.56},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11665.82,"10th_percentile":11665.82,"90th_percentile":11665.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis With Principal Diagnosis Pulmonary Embolism","code_information":[{"code":"173","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21371.9,"maximum":35457.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35457.85},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21371.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34228.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21371.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33930.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21371.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27662.66},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26897.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"168","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10062.53,"maximum":16277.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16277.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10062.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15713.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10062.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15576.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10062.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12699.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12348.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Cc","code_information":[{"code":"167","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13132.22,"maximum":21483.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21483.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13132.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20739.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13132.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20558.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13132.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16760.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16297.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Respiratory System O.R. Procedures With Mcc","code_information":[{"code":"166","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26719.61,"maximum":44527.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44527.22},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26719.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42983.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26719.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42609.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26719.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34738.18},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33777.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures Without Cc/Mcc","code_information":[{"code":"165","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13910.53,"maximum":22803.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22803.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13910.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22013.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13910.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21821.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13910.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17790.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17298.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Cc","code_information":[{"code":"164","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18194.04,"maximum":30068.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30068.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18194.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29026.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18194.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28773.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18194.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23458.06},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22809.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Chest Procedures With Mcc","code_information":[{"code":"163","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31946.51,"maximum":53391.68,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53391.68},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31946.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51540.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31946.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51092.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31946.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41653.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40502.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases Without Cc/Mcc","code_information":[{"code":"159","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5441.14,"maximum":8440.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8440.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5441.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8147.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5441.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8076.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5441.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6584.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6402.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Cc","code_information":[{"code":"158","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6855.17,"maximum":10838.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10838.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6855.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10462.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6855.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10371.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6855.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8455.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8221.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dental And Oral Diseases With Mcc","code_information":[{"code":"157","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12523.9,"maximum":20452.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20452.24},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12523.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19743.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12523.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19571.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12523.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15955.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15514.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses Without Cc/Mcc","code_information":[{"code":"156","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5318.92,"maximum":8233.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8233.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5318.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7947.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5318.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7878.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5318.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6423.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6245.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Cc","code_information":[{"code":"155","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6902.23,"maximum":10918.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10918.26},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6902.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10539.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6902.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10448.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6902.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8517.95},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8282.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat Diagnoses With Mcc","code_information":[{"code":"154","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11447.05,"maximum":18625.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18625.98},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11447.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17980.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11447.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17823.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11447.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14531.17},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14129.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri Without Mcc","code_information":[{"code":"153","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5649.77,"maximum":8794.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8794.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5649.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8489.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5649.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8415.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5649.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6860.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6671.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Otitis Media And Uri With Mcc","code_information":[{"code":"152","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8768.63,"maximum":14083.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14083.55},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8768.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13595.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8768.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13477.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8768.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10987.37},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10683.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis Without Mcc","code_information":[{"code":"151","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5620.27,"maximum":8744.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8744.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5620.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8441.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5620.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8367.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5620.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6821.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6633.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Epistaxis With Mcc","code_information":[{"code":"150","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9817.38,"maximum":15862.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15862.16},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9817.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15312.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9817.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15179.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9817.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12374.96},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12032.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Dysequilibrium","code_information":[{"code":"149","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5743.9,"maximum":8953.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8953.81},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5743.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8643.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5743.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8568.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5743.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6985.37},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6792.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy Without Cc/Mcc","code_information":[{"code":"148","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6063.51,"maximum":9495.85,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9495.85},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9166.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9086.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6063.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7408.25},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7203.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Cc","code_information":[{"code":"147","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9395.91,"maximum":15147.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15147.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9395.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14622.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9395.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14495.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9395.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11817.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11490.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ear, Nose, Mouth And Throat Malignancy With Mcc","code_information":[{"code":"146","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15337.89,"maximum":25224.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25224.59},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15337.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24350.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15337.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24138.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15337.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19679.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19134.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures Without Cc/Mcc","code_information":[{"code":"145","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8909.82,"maximum":14323.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14323.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8909.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13826.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8909.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13706.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8909.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11174.18},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10865.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. Procedures With Cc","code_information":[{"code":"144","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12636.99,"maximum":20644.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20644.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12636.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19928.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12636.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19755.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12636.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16105.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15660.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth And Throat O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures Without Cc/Mcc","code_information":[{"code":"142","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11678.15,"maximum":19017.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19017.91},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11678.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18358.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11678.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18198.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11678.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14836.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14426.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head And Neck Procedures With Mcc","code_information":[{"code":"140","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30425.71,"maximum":50812.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50812.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30425.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49050.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30425.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48624.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30425.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39641.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38545.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures","code_information":[{"code":"139","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9144.44,"maximum":14720.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14720.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9144.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14210.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9144.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14086.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9144.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11484.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11167.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures Without Cc/Mcc","code_information":[{"code":"138","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6689.39,"maximum":10557.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10557.3},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6689.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10191.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6689.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10102.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6689.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8236.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8008.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures With Cc/Mcc","code_information":[{"code":"137","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10953.23,"maximum":17788.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17788.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10953.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17171.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10953.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17022.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10953.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13877.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13494.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures Without Cc/Mcc","code_information":[{"code":"136","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7596.25,"maximum":12095.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12095.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7596.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11675.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7596.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11574.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7596.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9436.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9175.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sinus And Mastoid Procedures With Cc/Mcc","code_information":[{"code":"135","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15707.38,"maximum":25851.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25851.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15707.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24955.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15707.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24738.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15707.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20167.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19610.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye Without Mcc","code_information":[{"code":"125","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5857.69,"maximum":9146.8,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9146.8},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5857.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8829.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5857.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8752.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5857.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7135.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6938.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of The Eye With Mcc Or Thrombolytic Agent","code_information":[{"code":"124","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9758.37,"maximum":15762.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15762.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9758.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15215.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9758.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15083.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9758.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12296.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11956.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological Eye Disorders","code_information":[{"code":"123","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6074.05,"maximum":9513.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9513.72},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6074.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9183.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6074.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9104.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6074.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7422.19},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7216.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections Without Cc/Mcc","code_information":[{"code":"122","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5984.13,"maximum":9361.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9361.24},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5984.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9036.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5984.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8958.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5984.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7303.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7101.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections With Cc/Mcc","code_information":[{"code":"121","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8635.86,"maximum":13858.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13858.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8635.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13377.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8635.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13261.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8635.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10811.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10512.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures Without Cc/Mcc","code_information":[{"code":"117","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8085.15,"maximum":12924.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12924.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8085.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12476.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8085.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12367.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8085.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10083.06},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9804.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intraocular Procedures With Cc/Mcc","code_information":[{"code":"116","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13165.23,"maximum":21539.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21539.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13165.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20793.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13165.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20612.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13165.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16804.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16339.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extraocular Procedures Except Orbit","code_information":[{"code":"115","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11246.15,"maximum":18285.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18285.26},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11246.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17651.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11246.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17497.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11246.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14265.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13870.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures Without Cc/Mcc","code_information":[{"code":"114","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9968.4,"maximum":16118.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16118.29},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9968.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15559.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9968.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15424.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9968.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12574.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12227.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Orbital Procedures With Cc/Mcc","code_information":[{"code":"113","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16979.51,"maximum":28008.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28008.65},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16979.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27037.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16979.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26802.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16979.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21851.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21246.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches Without Mcc","code_information":[{"code":"103","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6338.87,"maximum":9962.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9962.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6338.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9617.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6338.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9533.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6338.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7772.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7557.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Headaches With Mcc","code_information":[{"code":"102","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8338.03,"maximum":13353.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13353.28},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8338.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12890.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8338.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12778.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8338.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10417.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10129.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Seizures Without Mcc","code_information":[{"code":"101","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6804.59,"maximum":10752.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10752.67},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6804.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10379.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6804.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10289.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6804.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8388.76},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8156.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis Without Cc/Mcc","code_information":[{"code":"099","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10034.43,"maximum":16230.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16230.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10034.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15667.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10034.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15531.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10034.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12662.15},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12312.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Cc","code_information":[{"code":"098","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16584.73,"maximum":27339.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27339.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16584.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26391.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16584.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26161.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16584.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21328.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20739.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Bacterial Infection Of Nervous System Except Viral Meningitis With Mcc","code_information":[{"code":"097","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25835.23,"maximum":43027.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43027.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25835.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41535.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25835.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41174.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25835.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33568.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32639.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System Without Cc/Mcc","code_information":[{"code":"096","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18581.79,"maximum":30726.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30726.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18581.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29660.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18581.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29402.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18581.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23971.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23308.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Cc","code_information":[{"code":"095","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18581.79,"maximum":30726.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30726.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18581.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29660.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18581.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29402.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18581.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23971.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23308.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bacterial And Tuberculous Infections Of Nervous System With Mcc","code_information":[{"code":"094","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25186.18,"maximum":41926.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41926.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25186.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40473.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25186.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40121.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25186.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32709.3},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31804.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System Without Cc/Mcc","code_information":[{"code":"093","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6057.89,"maximum":9486.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9486.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9157.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9077.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6057.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7400.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7196.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Cc","code_information":[{"code":"092","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7650.33,"maximum":12187.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12187.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7650.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11764.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7650.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11662.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7650.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9507.76},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9244.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders Of Nervous System With Mcc","code_information":[{"code":"091","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12800.66,"maximum":20921.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20921.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12800.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20196.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12800.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20020.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12800.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16322.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15870.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion Without Cc/Mcc","code_information":[{"code":"090","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6246.85,"maximum":9806.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9806.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9466.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9384.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6246.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7650.82},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7439.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Cc","code_information":[{"code":"089","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8181.38,"maximum":13087.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13087.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8181.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12633.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8181.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12524.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8181.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10210.39},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9928.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Concussion With Mcc","code_information":[{"code":"088","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9959.97,"maximum":16103.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16103.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9959.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15545.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9959.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15410.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9959.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12563.63},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12216.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour Without Cc/Mcc","code_information":[{"code":"087","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6889.59,"maximum":10896.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10896.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10519.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10427.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6889.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8501.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8266.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Cc","code_information":[{"code":"086","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9615.07,"maximum":15519.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15519.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9615.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14981.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9615.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14850.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9615.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12107.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11772.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma <1 Hour With Mcc","code_information":[{"code":"085","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16423.17,"maximum":27065.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27065.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16423.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26126.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16423.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25899.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16423.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21115.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20531.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour Without Cc/Mcc","code_information":[{"code":"084","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7178.29,"maximum":11386.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11386.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7178.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10991.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7178.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10896.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7178.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8883.21},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8637.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Cc","code_information":[{"code":"083","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10269.05,"maximum":16628.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16628.17},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10269.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16051.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10269.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15912.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10269.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12972.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12613.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Stupor And Coma >1 Hour With Mcc","code_information":[{"code":"082","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16519.41,"maximum":27228.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27228.35},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16519.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26284.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16519.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26055.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16519.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21242.37},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20654.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma Without Mcc","code_information":[{"code":"081","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6755.42,"maximum":10669.28,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10669.28},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6755.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10299.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6755.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10209.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6755.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8323.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8093.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nontraumatic Stupor And Coma With Mcc","code_information":[{"code":"080","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13178.58,"maximum":21562.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21562.53},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13178.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20815.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13178.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20634.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13178.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16822.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16356.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis Without Cc/Mcc","code_information":[{"code":"076","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6260.9,"maximum":9830.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9830.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6260.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9489.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6260.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9407.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6260.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7669.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7457.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Meningitis With Cc/Mcc","code_information":[{"code":"075","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13933.71,"maximum":22843.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22843.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13933.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22051.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13933.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21859.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13933.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17821.25},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17328.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders Without Mcc","code_information":[{"code":"074","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7705.12,"maximum":12279.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12279.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7705.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11854.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7705.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11751.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7705.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9580.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial And Peripheral Nerve Disorders With Mcc","code_information":[{"code":"073","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11733.65,"maximum":19112.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19112.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11733.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18449.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11733.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18289.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11733.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14910.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14498.06}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders Without Cc/Mcc","code_information":[{"code":"072","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5776.21,"maximum":9008.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9008.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5776.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8696.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5776.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8620.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5776.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7028.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6833.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Cc","code_information":[{"code":"071","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7671.41,"maximum":12222.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12222.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7671.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11799.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7671.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11696.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7671.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9535.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9271.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cerebrovascular Disorders With Mcc","code_information":[{"code":"070","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12158.63,"maximum":19832.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19832.76},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19145.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18978.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12158.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15472.65},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15044.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transient Ischemia Without Thrombolytic","code_information":[{"code":"069","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6075.45,"maximum":9516.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9516.1},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6075.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9186.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6075.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9106.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6075.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7424.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7218.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction Without Mcc","code_information":[{"code":"068","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6536.26,"maximum":10297.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10297.6},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6536.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9940.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6536.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9854.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6536.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8033.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7811.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Precerebral Occlusion Without Infarction With Mcc","code_information":[{"code":"067","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10781.13,"maximum":17496.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17496.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10781.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16890.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10781.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16743.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10781.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13650.1},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13272.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction Without Cc/Mcc","code_information":[{"code":"066","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5271.85,"maximum":8153.26,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8153.26},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5271.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7870.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5271.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7802.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5271.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6360.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6184.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Cc Or Tpa In 24 Hours","code_information":[{"code":"065","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7561.12,"maximum":12035.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12035.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7561.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11618.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7561.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11517.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7561.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9389.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9130.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8808.14,"10th_percentile":8808.14,"90th_percentile":8808.14,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5443.84,"10th_percentile":5443.84,"90th_percentile":5443.84,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Hemorrhage Or Cerebral Infarction With Mcc","code_information":[{"code":"064","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14590.49,"maximum":23957.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23957.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14590.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23126.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14590.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22925.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14590.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18690.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18173.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent Without Cc/Mcc","code_information":[{"code":"063","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10325.25,"maximum":16723.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16723.47},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10325.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16143.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10325.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16003.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10325.25,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13046.92},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12686.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Cc","code_information":[{"code":"062","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12807.69,"maximum":20933.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20933.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12807.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20207.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12807.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20032.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12807.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16331.42},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15879.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ischemic Stroke, Precerebral Occlusion Or Transient Ischemia With Thrombolytic Agent With Mcc","code_information":[{"code":"061","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19831.44,"maximum":32845.33,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32845.33},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19831.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31706.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19831.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31430.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19831.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25624.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24915.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia Without Cc/Mcc","code_information":[{"code":"060","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6925.41,"maximum":10957.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10957.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6925.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10577.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6925.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10485.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6925.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8548.62},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8312.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Cc","code_information":[{"code":"059","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9180.96,"maximum":14782.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14782.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9180.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14270.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9180.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14146.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9180.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11532.92},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11214.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Sclerosis And Cerebellar Ataxia With Mcc","code_information":[{"code":"058","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12472.62,"maximum":20365.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20365.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12472.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19659.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12472.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19488.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12472.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15888.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15448.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders Without Mcc","code_information":[{"code":"057","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9565.2,"maximum":15434.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15434.48},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9565.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14899.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9565.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14769.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9565.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12041.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11708.34}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Degenerative Nervous System Disorders With Mcc","code_information":[{"code":"056","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16782.82,"maximum":27675.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27675.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16782.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26715.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16782.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26483.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16782.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21590.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20993.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms Without Mcc","code_information":[{"code":"055","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7626.45,"maximum":12146.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12146.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11725.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11623.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7626.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9476.16},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9214.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Nervous System Neoplasms With Mcc","code_information":[{"code":"054","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11189.96,"maximum":18189.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18189.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11189.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17559.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11189.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17406.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11189.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14191.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13798.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries Without Cc/Mcc","code_information":[{"code":"053","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7342.66,"maximum":11665.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11665.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7342.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11260.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7342.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11162.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7342.66,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9100.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8849.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Disorders And Injuries With Cc/Mcc","code_information":[{"code":"052","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13187.71,"maximum":21578.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21578.02},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13187.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20829.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13187.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20648.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13187.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16834.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16368.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures Without Cc/Mcc","code_information":[{"code":"042","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12600.47,"maximum":20582.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20582.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12600.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19868.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12600.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19695.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12600.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16057.24},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15613.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Cc Or Peripheral Neurostimulator","code_information":[{"code":"041","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15908.98,"maximum":26193.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26193.11},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15908.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25285.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15908.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25065.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15908.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20434.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19869.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral, Cranial Nerve And Other Nervous System Procedures With Mcc","code_information":[{"code":"040","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27587.13,"maximum":45998.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45998.48},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27587.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44403.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27587.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44017.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27587.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35885.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34893.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures Without Cc/Mcc","code_information":[{"code":"039","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8721.56,"maximum":14003.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14003.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8721.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13518.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8721.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13400.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8721.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10925.1},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10622.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Cc","code_information":[{"code":"038","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11862.2,"maximum":19330.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19330.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11862.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18659.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11862.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18497.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11862.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15080.44},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14663.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extracranial Procedures With Mcc","code_information":[{"code":"037","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23589.52,"maximum":39218.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39218.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23589.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37859.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23589.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37529.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23589.52,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30596.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29750.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures Without Cc/Mcc","code_information":[{"code":"036","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14111.42,"maximum":23144.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23144.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14111.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22342.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14111.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22147.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14111.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18056.38},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17557.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Cc","code_information":[{"code":"035","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17256.27,"maximum":28478.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28478.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17256.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27490.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17256.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27251.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17256.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22217.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21602.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Carotid Artery Stent Procedures With Mcc","code_information":[{"code":"034","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27653.87,"maximum":46111.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46111.65},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27653.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44513.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27653.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44125.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27653.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35974.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34979.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures Without Cc/Mcc","code_information":[{"code":"033","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12145.28,"maximum":19810.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19810.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12145.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19123.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12145.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18957.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12145.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15454.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15027.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Cc","code_information":[{"code":"032","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15433.43,"maximum":25386.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25386.6},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15433.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24506.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15433.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24293.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15433.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19805.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19257.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures With Mcc","code_information":[{"code":"031","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":31937.38,"maximum":53376.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53376.2},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31937.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51525.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31937.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51077.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":31937.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41641.77},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40490.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures Without Cc/Mcc","code_information":[{"code":"030","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15884.4,"maximum":26151.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26151.42},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15884.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25244.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15884.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25025.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15884.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20402.19},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19838.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":28544.92,"10th_percentile":28544.92,"90th_percentile":28544.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Cc Or Spinal Neurostimulators","code_information":[{"code":"029","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24428.94,"maximum":40642.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40642.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24428.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39233.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24428.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38892.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24428.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31707.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30830.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures With Mcc","code_information":[{"code":"028","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42669.33,"maximum":71576.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71576.88},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42669.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69095.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42669.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68494.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42669.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55841.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54297.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures Without Cc/Mcc","code_information":[{"code":"027","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18186.31,"maximum":30055.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30055.31},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18186.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29013.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18186.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28761.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18186.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23447.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22799.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Cc","code_information":[{"code":"026","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22304.75,"maximum":37039.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37039.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22304.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35755.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22304.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35444.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22304.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28896.9},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28097.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy And Endovascular Intracranial Procedures With Mcc","code_information":[{"code":"025","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32402.39,"maximum":54164.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54164.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32402.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52287.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32402.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51832.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32402.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42257.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41088.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis Without Mcc","code_information":[{"code":"024","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27943.27,"maximum":46602.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46602.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27943.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44986.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27943.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44595.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27943.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36357.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35351.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy With Major Device Implant Or Acute Complex Cns Principal Diagnosis With Mcc Or Antineopla","code_information":[{"code":"023","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40716.54,"maximum":68265.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68265.06},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40716.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65898.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40716.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65325.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40716.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53257.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51784.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage Without Cc/Mcc","code_information":[{"code":"022","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22783.81,"maximum":37852.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37852.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22783.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36540.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22783.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36222.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22783.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29530.76},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28714.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Cc","code_information":[{"code":"021","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37650.36,"maximum":63065.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63065.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37650.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60878.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37650.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60349.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37650.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49200.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47840.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Procedures With Principal Diagnosis Hemorrhage With Mcc","code_information":[{"code":"020","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":55738.33,"maximum":93741.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93741.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55738.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":90491.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55738.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":89704.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":55738.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":73132.63},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71110.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas And Kidney Transplant With Hemodialysis","code_information":[{"code":"019","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50580.97,"maximum":84994.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84994.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50580.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82047.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50580.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81334.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50580.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66308.97},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64475.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chimeric Antigen Receptor (Car) T-Cell And Other Immunotherapies","code_information":[{"code":"018","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":303799.82,"maximum":514436.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":514436.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303799.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":496602.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303799.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":492283.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":303799.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":401340.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":390242.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy Without Cc/Mcc","code_information":[{"code":"013","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20707.39,"maximum":34330.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34330.88},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20707.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33140.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20707.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32852.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20707.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26783.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26042.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Cc","code_information":[{"code":"012","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30079.41,"maximum":50225.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50225.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30079.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48484.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30079.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48062.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30079.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39183.5},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38099.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy For Face, Mouth And Neck Diagnoses Or Laryngectomy With Mcc","code_information":[{"code":"011","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38776.38,"maximum":64974.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64974.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38776.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62722.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38776.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62176.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38776.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50690.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49288.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas Transplant","code_information":[{"code":"010","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50869.68,"maximum":85484.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85484.11},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50869.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82520.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50869.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81802.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50869.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66690.96},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64846.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Simultaneous Pancreas And Kidney Transplant","code_information":[{"code":"008","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39833.56,"maximum":66767.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66767.6},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39833.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64452.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39833.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63892.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39833.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52089.15},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50648.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lung Transplant","code_information":[{"code":"007","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":91432.38,"maximum":154275.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":154275.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91432.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":148927.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91432.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":147632.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":91432.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":120359.16},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117030.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant Without Mcc","code_information":[{"code":"006","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33036.7,"maximum":55240.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55240.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33036.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53325.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33036.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52861.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33036.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43096.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41904.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Liver Transplant With Mcc Or Intestinal Transplant","code_information":[{"code":"005","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":72889.93,"maximum":122828.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":122828.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72889.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":118570.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72889.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":117539.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":72889.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95825.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":93175.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck Without Major O.R.","code_information":[{"code":"004","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":97762.81,"maximum":165011.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":165011.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97762.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":159291.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97762.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":157905.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":97762.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":128734.91},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125175.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ecmo Or Tracheostomy With Mv >96 Hours Or Principal Diagnosis Except Face, Mouth And Neck With Major","code_information":[{"code":"003","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":149559.71,"maximum":252855.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":252855.81},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149559.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":244089.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149559.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":241967.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":149559.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":197267.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":191812.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System Without Mcc","code_information":[{"code":"002","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":80064.0,"maximum":134995.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":134995.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80064.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":130315.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80064.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":129182.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":80064.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":105317.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102405.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Transplant Or Implant Of Heart Assist System With Mcc","code_information":[{"code":"001","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":197316.85,"maximum":333848.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":333848.72},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197316.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":322274.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197316.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":319472.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":197316.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":260454.13},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":253251.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System Diagnoses Without Cc/Mcc","code_information":[{"code":"395","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5023.19,"maximum":7731.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7731.54},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5023.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7463.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5023.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7398.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5023.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6031.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5865.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Mcc","code_information":[{"code":"397","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17287.18,"maximum":28530.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28530.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17287.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27541.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17287.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27301.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17287.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22258.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21642.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16985.52,"10th_percentile":16985.52,"90th_percentile":16985.52,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures With Cc","code_information":[{"code":"398","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11096.53,"maximum":18031.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18031.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11096.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17406.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11096.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17255.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11096.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14067.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13678.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":29106.34,"10th_percentile":29106.34,"90th_percentile":29106.34,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendix Procedures Without Cc/Mcc","code_information":[{"code":"399","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8505.21,"maximum":13636.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13636.81},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8505.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13164.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8505.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13049.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8505.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10638.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10344.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":4125.97,"10th_percentile":4125.97,"90th_percentile":4125.97,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Combined Anterior And Posterior Spinal Fusion Except Cervical","code_information":[{"code":"402","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28706.13,"maximum":47896.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47896.22},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28706.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46235.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28706.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45833.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28706.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37366.53},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36333.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Mcc","code_information":[{"code":"405","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":38891.58,"maximum":65170.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65170.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38891.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62910.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38891.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62363.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":38891.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50842.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49436.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pancreas, Liver And Shunt Procedures With Cc","code_information":[{"code":"406","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20836.63,"maximum":34550.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34550.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20836.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33352.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20836.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33062.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20836.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26954.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26209.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biliary Tract Procedures Except Only Cholecystectomy With Or Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. With Mcc","code_information":[{"code":"411","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23668.19,"maximum":39352.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39352.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23668.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37987.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23668.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37657.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23668.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30700.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29851.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy With C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cholecystectomy Except By Laparoscope Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopic Cholecystectomy Without C.D.E. Without Cc/Mcc","code_information":[{"code":"419","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10058.32,"maximum":16270.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16270.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10058.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15706.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10058.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15570.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10058.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12693.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12342.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Mcc","code_information":[{"code":"420","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24397.33,"maximum":40588.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40588.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24397.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39181.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24397.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38840.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24397.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31665.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30789.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures With Cc","code_information":[{"code":"421","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12669.3,"maximum":20698.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20698.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12669.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19981.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12669.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19807.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12669.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16148.33},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15701.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hepatobiliary Diagnostic Procedures Without Cc/Mcc","code_information":[{"code":"422","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10295.04,"maximum":16672.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16672.24},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10295.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16094.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10295.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15954.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10295.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13006.95},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12647.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Mcc","code_information":[{"code":"423","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29636.87,"maximum":49474.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49474.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29636.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47759.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29636.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47344.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29636.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38597.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37530.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures With Cc","code_information":[{"code":"424","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15833.12,"maximum":26064.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26064.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15833.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25160.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15833.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24942.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15833.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20334.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19772.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Hepatobiliary Or Pancreas O.R. Procedures Without Cc/Mcc","code_information":[{"code":"425","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11003.1,"maximum":17873.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17873.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11003.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17253.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11003.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17103.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11003.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13943.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13558.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Mcc Or Custom-Made","code_information":[{"code":"426","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":77882.21,"maximum":131295.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":131295.56},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77882.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":126743.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77882.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":125641.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":77882.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102431.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99598.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical With Cc","code_information":[{"code":"427","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":51171.03,"maximum":85995.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85995.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51171.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83013.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51171.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82292.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":51171.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67089.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65234.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Combined Anterior And Posterior Spinal Fusion Except Cervical Without Cc/Mcc","code_information":[{"code":"428","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39955.79,"maximum":66974.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66974.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39955.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64653.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39955.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64090.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39955.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52250.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50806.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion With Mcc","code_information":[{"code":"429","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":63751.82,"maximum":107331.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":107331.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63751.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103610.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63751.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":102709.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":63751.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":83735.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81419.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Cervical Spinal Fusion Without Mcc","code_information":[{"code":"430","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40975.04,"maximum":68703.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68703.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40975.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66321.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40975.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65744.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40975.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53599.43},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52117.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Mcc","code_information":[{"code":"432","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14289.85,"maximum":23447.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23447.17},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14289.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22634.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14289.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22437.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14289.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18292.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17786.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16238.33,"10th_percentile":16238.33,"90th_percentile":16238.33,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis With Cc","code_information":[{"code":"433","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7883.55,"maximum":12582.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12582.51},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7883.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12146.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7883.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12040.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7883.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9816.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9544.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cirrhosis And Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"434","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5469.24,"maximum":8488.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8488.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5469.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8193.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5469.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8122.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5469.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6621.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6438.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Mcc","code_information":[{"code":"435","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13366.13,"maximum":21880.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21880.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13366.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21122.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13366.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20938.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13366.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17070.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16598.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas With Cc","code_information":[{"code":"436","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8409.68,"maximum":13474.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13474.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8409.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13007.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8409.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12894.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8409.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10512.44},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10221.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy Of Hepatobiliary System Or Pancreas Without Cc/Mcc","code_information":[{"code":"437","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6458.28,"maximum":10165.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10165.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6458.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9812.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6458.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9727.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6458.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7930.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7711.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Mcc","code_information":[{"code":"438","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11915.58,"maximum":19420.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19420.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11915.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18747.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11915.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18584.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11915.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15151.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14732.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy With Cc","code_information":[{"code":"439","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6373.29,"maximum":10021.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10021.22},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9673.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9589.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7818.11},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7601.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":13425.22,"10th_percentile":13425.22,"90th_percentile":13425.22,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6277.62,"10th_percentile":6277.62,"90th_percentile":6277.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":14440.5,"10th_percentile":14440.5,"90th_percentile":14440.5,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Pancreas Except Malignancy Without Cc/Mcc","code_information":[{"code":"440","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4829.31,"maximum":7402.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7402.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4829.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7146.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4829.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7083.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4829.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5775.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5615.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":550.0,"10th_percentile":550.0,"90th_percentile":550.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis With Cc","code_information":[{"code":"442","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7245.02,"maximum":11499.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11499.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7245.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11100.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7245.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11004.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7245.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8971.5},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8723.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":825.0,"10th_percentile":825.0,"90th_percentile":825.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Liver Except Malignancy, Cirrhosis Or Alcoholic Hepatitis Without Cc/Mcc","code_information":[{"code":"443","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5379.33,"maximum":8335.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8335.53},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5379.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8046.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5379.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7976.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5379.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6503.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6323.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Mcc","code_information":[{"code":"444","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12201.48,"maximum":19905.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19905.43},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12201.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19215.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12201.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19048.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12201.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15529.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15099.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract With Cc","code_information":[{"code":"445","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8151.88,"maximum":13037.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13037.59},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8151.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12585.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8151.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12476.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8151.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10171.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9890.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of The Biliary Tract Without Cc/Mcc","code_information":[{"code":"446","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6275.65,"maximum":9855.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9855.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9513.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9431.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6275.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7688.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7476.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody","code_information":[{"code":"447","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47398.9,"maximum":79597.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79597.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47398.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76838.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47398.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76170.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47398.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62098.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60381.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Multiple Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"448","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30253.62,"maximum":50520.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50520.65},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30253.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48769.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30253.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48345.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30253.62,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39414.0},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38324.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical With Mcc Or Custom-Made Anatomically Designed Interbody F","code_information":[{"code":"450","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37901.84,"maximum":63491.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63491.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37901.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61290.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37901.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60757.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37901.84,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49533.3},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48163.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Single Level Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"451","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23156.11,"maximum":38483.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38483.76},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23156.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37149.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23156.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36826.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23156.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30023.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29193.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"456","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":59493.6,"maximum":100109.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":100109.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59493.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":96639.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59493.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":95798.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":59493.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78101.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75941.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"457","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42351.83,"maximum":71038.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71038.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42351.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68575.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42351.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67979.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42351.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55421.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53888.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Spinal Curvature, Malignancy, Infection Or Extensive Fusions With","code_information":[{"code":"458","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29774.55,"maximum":49708.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49708.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29774.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47984.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29774.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47567.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29774.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38780.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37707.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity With Mcc","code_information":[{"code":"461","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39260.37,"maximum":65795.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65795.5},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39260.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63514.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39260.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62962.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39260.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51330.76},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49911.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bilateral Or Multiple Major Joint Procedures Of Lower Extremity Without Mcc","code_information":[{"code":"462","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19149.36,"maximum":31688.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31688.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19149.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30590.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19149.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30324.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19149.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24722.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24038.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"463","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":40500.18,"maximum":67898.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67898.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40500.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65544.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40500.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64974.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":40500.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52971.15},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51506.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridement And Skin Graft Except Hand For Musculoskeletal And Connective Tissue Disorders Wit","code_information":[{"code":"464","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22343.38,"maximum":37105.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37105.42},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22343.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35819.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22343.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35507.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22343.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28948.02},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28147.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24318.27,"10th_percentile":24318.27,"90th_percentile":24318.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement With Mcc","code_information":[{"code":"466","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":37029.4,"maximum":62011.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62011.93},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37029.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59862.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37029.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59341.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":37029.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48378.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47041.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24792.34,"10th_percentile":24792.34,"90th_percentile":28267.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Revision Of Hip Or Knee Replacement Without Cc/Mcc","code_information":[{"code":"468","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19767.51,"maximum":32736.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32736.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19767.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31602.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19767.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31327.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19767.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25539.91},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24833.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21679.56,"10th_percentile":21679.56,"90th_percentile":21679.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21678.63,"10th_percentile":21678.63,"90th_percentile":21678.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":28845.76,"10th_percentile":28845.76,"90th_percentile":28845.76,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Cc","code_information":[{"code":"300","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7962.92,"maximum":12717.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12717.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7962.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12276.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7962.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12169.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7962.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9921.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9647.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Peripheral Vascular Disorders With Mcc","code_information":[{"code":"299","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11933.14,"maximum":19450.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19450.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11933.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18776.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11933.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18612.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11933.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15174.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14754.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained Without Cc/Mcc","code_information":[{"code":"298","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":3661.15,"maximum":5421.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5421.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3661.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5233.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3661.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5188.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":3661.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4229.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4112.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Cc","code_information":[{"code":"297","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4917.82,"maximum":7552.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7552.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4917.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7291.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4917.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7227.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4917.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5892.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5729.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Arrest, Unexplained With Mcc","code_information":[{"code":"296","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11435.81,"maximum":18606.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18606.91},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11435.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17961.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11435.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17805.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11435.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14516.3},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14114.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8206.44,"10th_percentile":8206.44,"90th_percentile":8206.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock Without Cc/Mcc","code_information":[{"code":"293","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4440.16,"maximum":6742.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6742.76},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4440.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6509.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4440.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6452.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4440.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5260.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5114.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure And Shock With Cc","code_information":[{"code":"292","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6428.08,"maximum":10114.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10114.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6428.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9763.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6428.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9678.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6428.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7890.61},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7672.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6343.04,"10th_percentile":6343.04,"90th_percentile":6343.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":5941.3,"10th_percentile":5941.3,"90th_percentile":5941.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":18888.01,"10th_percentile":18888.01,"90th_percentile":18888.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10829.73,"10th_percentile":10829.73,"90th_percentile":11146.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10796.22,"10th_percentile":9314.62,"90th_percentile":10822.4,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":13696.49,"10th_percentile":13696.49,"90th_percentile":13696.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":84.88,"10th_percentile":84.88,"90th_percentile":84.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Acute And Subacute Endocarditis Without Cc/Mcc","code_information":[{"code":"290","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6994.95,"maximum":11075.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11075.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6994.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10691.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6994.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10598.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6994.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8640.63},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8401.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute And Subacute Endocarditis With Mcc","code_information":[{"code":"288","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19473.89,"maximum":32238.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32238.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19473.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31121.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19473.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30850.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19473.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25151.42},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24455.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization Without Mcc","code_information":[{"code":"287","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7981.19,"maximum":12748.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12748.1},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7981.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12306.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7981.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12199.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7981.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9945.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9670.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":23420.58,"10th_percentile":23420.58,"90th_percentile":23420.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":11438.58,"10th_percentile":11232.84,"90th_percentile":32722.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":8364.09,"10th_percentile":8364.09,"90th_percentile":8364.09,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Circulatory Disorders Except Ami, With Cardiac Catheterization With Mcc","code_information":[{"code":"286","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16008.03,"maximum":26361.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26361.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16008.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25447.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16008.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25225.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16008.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20565.76},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19997.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":23233.01,"10th_percentile":23233.01,"90th_percentile":23233.01,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired Without Cc/Mcc","code_information":[{"code":"285","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4671.26,"maximum":7134.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7134.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4671.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6887.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4671.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6827.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4671.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5566.18},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5412.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Cc","code_information":[{"code":"284","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5326.65,"maximum":8246.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8246.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7960.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7891.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5326.65,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6433.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6255.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Expired With Mcc","code_information":[{"code":"283","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14378.35,"maximum":23597.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23597.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14378.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22779.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14378.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22581.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14378.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18409.56},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17900.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive Without Cc/Mcc","code_information":[{"code":"282","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5543.7,"maximum":8614.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8614.29},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5543.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8315.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5543.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8243.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5543.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6720.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6534.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Cc","code_information":[{"code":"281","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6920.49,"maximum":10949.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10949.24},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6920.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10569.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6920.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10477.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6920.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8542.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8305.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6838.58,"10th_percentile":6838.58,"90th_percentile":6838.58,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Myocardial Infarction, Discharged Alive With Mcc","code_information":[{"code":"280","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11732.24,"maximum":19109.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19109.64},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18447.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18286.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11732.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14908.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14496.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures Without Mcc","code_information":[{"code":"279","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25797.3,"maximum":42963.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42963.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25797.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41473.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25797.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41112.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25797.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33517.88},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32591.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ultrasound Accelerated And Other Thrombolysis Of Peripheral Vascular Structures With Mcc","code_information":[{"code":"278","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39563.82,"maximum":66310.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66310.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39563.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64011.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39563.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63454.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39563.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51732.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50301.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Mcc","code_information":[{"code":"277","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32906.75,"maximum":55020.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55020.19},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32906.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53112.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32906.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52650.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32906.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42924.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41737.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Mcc Or Carotid Sinus Neurostimulator","code_information":[{"code":"276","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42657.39,"maximum":71556.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":71556.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42657.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69075.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42657.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68475.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42657.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55825.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54281.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization And Mcc","code_information":[{"code":"275","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50551.47,"maximum":84944.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":84944.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50551.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81999.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50551.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81286.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50551.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66269.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64437.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures Without Mcc","code_information":[{"code":"274","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23586.71,"maximum":39214.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39214.02},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23586.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37854.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23586.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37525.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23586.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30593.06},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29747.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous And Other Intracardiac Procedures With Mcc","code_information":[{"code":"273","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29443.7,"maximum":49147.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49147.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29443.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47443.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29443.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47030.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29443.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38342.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37282.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Major Cardiovascular Procedures Without Cc/Mcc","code_information":[{"code":"272","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18397.75,"maximum":30413.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30413.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18397.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29359.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18397.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29104.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18397.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23727.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23071.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity With Mcc Or Total Ankle Repl","code_information":[{"code":"469","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21770.89,"maximum":36134.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36134.51},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21770.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34881.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21770.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34578.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21770.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28190.56},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27411.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hip And Knee Joint Replacement Or Reattachment Of Lower Extremity Without Mcc","code_information":[{"code":"470","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14013.78,"maximum":22978.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22978.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14013.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22182.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14013.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21989.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14013.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17927.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17431.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15590.82,"10th_percentile":15590.82,"90th_percentile":15590.82,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15579.03,"10th_percentile":15579.03,"90th_percentile":15579.03,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Mcc","code_information":[{"code":"471","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34383.29,"maximum":57524.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":57524.3},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34383.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55530.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34383.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55047.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34383.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44877.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43636.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion With Cc","code_information":[{"code":"472","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21159.06,"maximum":35096.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35096.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21159.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33880.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21159.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33585.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21159.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27381.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26623.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cervical Spinal Fusion Without Cc/Mcc","code_information":[{"code":"473","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17613.11,"maximum":29083.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29083.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17613.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28074.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17613.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27830.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17613.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22689.44},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22062.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Mcc","code_information":[{"code":"474","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":30619.59,"maximum":51141.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51141.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30619.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49368.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30619.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48939.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":30619.59,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39898.21},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38794.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Amputation For Musculoskeletal System And Connective Tissue Disorders With Cc","code_information":[{"code":"475","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16449.86,"maximum":27110.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27110.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16449.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26170.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16449.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25942.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16449.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21150.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20565.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17814.0,"10th_percentile":17814.0,"90th_percentile":17814.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":9196.81,"10th_percentile":9196.81,"90th_percentile":9196.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"478","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17738.85,"maximum":29296.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29296.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17738.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28280.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17738.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28034.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17738.85,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22855.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22223.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Biopsies Of Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"479","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13522.07,"maximum":22145.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22145.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13522.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21377.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13522.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21191.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13522.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17276.62},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16798.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Mcc","code_information":[{"code":"480","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20921.63,"maximum":34694.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34694.23},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20921.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33491.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20921.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33200.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20921.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27066.92},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26318.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint With Cc","code_information":[{"code":"481","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15177.03,"maximum":24951.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24951.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15177.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24086.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15177.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23877.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15177.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19466.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18928.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":11100.49,"10th_percentile":11100.49,"90th_percentile":11100.49,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14932.92,"10th_percentile":14932.92,"90th_percentile":14932.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17158.64,"10th_percentile":17158.64,"90th_percentile":18155.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip And Femur Procedures Except Major Joint Without Cc/Mcc","code_information":[{"code":"482","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11921.2,"maximum":19430.1,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19430.1},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11921.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18756.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11921.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18593.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11921.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15158.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14739.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Joint Or Limb Reattachment Procedures Of Upper Extremities","code_information":[{"code":"483","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19935.4,"maximum":33021.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33021.64},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19935.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31876.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19935.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31599.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19935.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25762.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25049.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Mcc","code_information":[{"code":"485","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23132.93,"maximum":38444.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38444.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23132.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37111.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23132.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36788.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23132.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29992.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29163.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection With Cc","code_information":[{"code":"486","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15153.15,"maximum":24911.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24911.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15153.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24047.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15153.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23838.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15153.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19434.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18897.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14885.86,"10th_percentile":14885.86,"90th_percentile":14885.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures With Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"487","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11466.02,"maximum":18658.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18658.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11466.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18011.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11466.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17854.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11466.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14556.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14153.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection With Cc/Mcc","code_information":[{"code":"488","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12889.87,"maximum":21072.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21072.91},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12889.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20342.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12889.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20165.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12889.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16440.16},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15985.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Knee Procedures Without Principal Diagnosis Of Infection Without Cc/Mcc","code_information":[{"code":"489","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8309.23,"maximum":13304.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13304.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12843.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12731.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10379.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10092.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Mcc","code_information":[{"code":"492","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26255.3,"maximum":43739.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43739.77},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26255.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42223.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26255.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41856.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26255.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34123.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33180.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur With Cc","code_information":[{"code":"493","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18279.03,"maximum":30212.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30212.56},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18279.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29165.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18279.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28911.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18279.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23570.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22918.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lower Extremity And Humerus Procedures Except Hip, Foot And Femur Without Cc/Mcc","code_information":[{"code":"494","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14558.88,"maximum":23903.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23903.43},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14558.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23074.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14558.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22874.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14558.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18648.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18132.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":34671.64,"10th_percentile":34671.64,"90th_percentile":34671.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":885.0,"10th_percentile":885.0,"90th_percentile":885.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Mcc","code_information":[{"code":"495","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25932.87,"maximum":43192.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43192.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25932.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41695.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25932.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41332.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25932.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33697.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32765.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur With Cc","code_information":[{"code":"496","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13135.73,"maximum":21489.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21489.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20744.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20564.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13135.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16765.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16301.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Except Hip And Femur Without Cc/Mcc","code_information":[{"code":"497","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8951.97,"maximum":14394.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14394.48},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8951.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13895.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8951.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13774.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8951.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11229.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10919.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur With Cc/Mcc","code_information":[{"code":"498","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21655.69,"maximum":35939.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35939.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21655.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34693.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21655.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34391.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21655.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28038.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27262.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Local Excision And Removal Of Internal Fixation Devices Of Hip And Femur Without Cc/Mcc","code_information":[{"code":"499","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14617.19,"maximum":24002.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24002.31},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14617.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23170.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14617.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22968.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14617.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18725.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18207.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Soft Tissue Procedures Without Cc/Mcc","code_information":[{"code":"502","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9918.53,"maximum":16033.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16033.71},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9918.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15477.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9918.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15343.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9918.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12508.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12162.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Mcc","code_information":[{"code":"503","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20070.27,"maximum":33250.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33250.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20070.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32097.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20070.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31818.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20070.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25940.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25223.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures With Cc","code_information":[{"code":"504","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13594.43,"maximum":22267.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22267.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13594.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21495.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13594.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21308.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13594.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17372.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16891.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Foot Procedures Without Cc/Mcc","code_information":[{"code":"505","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13057.76,"maximum":21357.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21357.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13057.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20617.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13057.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20437.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13057.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16662.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16201.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Thumb Or Joint Procedures","code_information":[{"code":"506","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9941.71,"maximum":16073.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16073.02},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9941.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15515.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9941.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15380.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9941.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12539.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12192.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures With Cc/Mcc","code_information":[{"code":"507","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13153.29,"maximum":21519.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21519.64},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13153.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20773.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13153.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20592.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13153.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16788.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16324.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Shoulder Or Elbow Joint Procedures Without Cc/Mcc","code_information":[{"code":"508","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11102.15,"maximum":18041.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18041.05},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11102.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17415.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11102.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17264.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11102.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14074.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13685.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Mcc","code_information":[{"code":"510","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21681.68,"maximum":35983.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35983.22},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21681.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34735.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21681.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34433.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21681.68,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28072.53},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27296.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures With Cc","code_information":[{"code":"511","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15070.96,"maximum":24771.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24771.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15070.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23913.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15070.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23705.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15070.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19325.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18791.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Shoulder, Elbow Or Forearm Procedures, Except Major Joint Procedures Without Cc/Mcc","code_information":[{"code":"512","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12092.6,"maximum":19720.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19720.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12092.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19037.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12092.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18871.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12092.6,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15385.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14959.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":39084.98,"10th_percentile":39084.98,"90th_percentile":39084.98,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures With Cc/Mcc","code_information":[{"code":"513","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11522.91,"maximum":18754.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18754.64},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11522.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18104.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11522.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17947.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11522.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14631.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14226.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Or Wrist Procedures, Except Major Thumb Or Joint Procedures Without Cc/Mcc","code_information":[{"code":"514","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7645.42,"maximum":12178.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12178.66},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7645.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11756.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7645.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11654.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7645.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9501.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9238.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Mcc","code_information":[{"code":"515","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22850.55,"maximum":37965.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37965.54},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22850.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36649.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22850.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36330.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22850.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29619.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28800.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures With Cc","code_information":[{"code":"516","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15061.83,"maximum":24756.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24756.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15061.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23898.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15061.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23690.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15061.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19313.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18779.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue O.R. Procedures Without Cc/Mcc","code_information":[{"code":"517","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11258.8,"maximum":18306.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18306.71},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11258.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17672.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11258.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17518.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11258.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14282.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13887.16}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Mcc Or Disc Device Or Neurostimulator","code_information":[{"code":"518","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26716.8,"maximum":44522.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44522.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26716.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42978.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26716.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42605.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26716.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34734.47},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33773.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion With Cc","code_information":[{"code":"519","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14514.63,"maximum":23828.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23828.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14514.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23002.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14514.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22802.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14514.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18589.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18075.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":29720.77,"10th_percentile":29720.77,"90th_percentile":29720.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":17327.55,"10th_percentile":17327.55,"90th_percentile":17327.55,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back And Neck Procedures Except Spinal Fusion Without Cc/Mcc","code_information":[{"code":"520","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10958.15,"maximum":17796.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17796.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10958.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17179.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10958.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17030.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10958.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13884.31},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13500.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture With Mcc","code_information":[{"code":"521","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20625.9,"maximum":34192.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34192.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20625.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33007.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20625.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32720.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20625.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26675.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25938.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip Replacement With Principal Diagnosis Of Hip Fracture Without Mcc","code_information":[{"code":"522","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15340.0,"maximum":25228.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25228.16},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15340.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24353.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15340.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24141.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15340.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19681.9},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19137.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fractures Of Femur With Mcc","code_information":[{"code":"533","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11476.55,"maximum":18676.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18676.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11476.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18028.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11476.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17871.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11476.55,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14570.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14167.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6039.94,"10th_percentile":6039.94,"90th_percentile":6039.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":321.06,"10th_percentile":321.06,"90th_percentile":321.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh With Cc/Mcc","code_information":[{"code":"537","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7167.75,"maximum":11368.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11368.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7167.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10974.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7167.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10879.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7167.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8869.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8624.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sprains, Strains, And Dislocations Of Hip, Pelvis And Thigh Without Cc/Mcc","code_information":[{"code":"538","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5524.03,"maximum":8580.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8580.93},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5524.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8283.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5524.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8211.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5524.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6694.47},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6509.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Mcc","code_information":[{"code":"539","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14300.38,"maximum":23465.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23465.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14300.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22651.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14300.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22454.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14300.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18306.39},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17800.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis With Cc","code_information":[{"code":"540","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9570.12,"maximum":15442.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15442.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9570.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14907.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9570.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14777.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9570.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12047.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11714.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Osteomyelitis Without Cc/Mcc","code_information":[{"code":"541","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5995.37,"maximum":9380.3,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9380.3},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5995.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9055.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5995.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8976.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5995.37,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7318.1},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7115.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Mcc","code_information":[{"code":"542","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12873.01,"maximum":21044.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21044.31},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12873.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20314.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12873.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20138.1},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12873.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16417.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15963.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy With Cc","code_information":[{"code":"543","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7685.46,"maximum":12246.56,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12246.56},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7685.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11822.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7685.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11719.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7685.46,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9554.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9290.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pathological Fractures And Musculoskeletal And Connective Tissue Malignancy Without Cc/Mcc","code_information":[{"code":"544","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5764.97,"maximum":8989.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8989.55},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5764.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8677.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5764.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8602.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5764.97,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7013.25},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6819.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6314.68,"10th_percentile":6314.68,"90th_percentile":6314.68,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Mcc","code_information":[{"code":"545","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17896.9,"maximum":29564.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29564.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28539.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28291.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17896.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23064.92},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22427.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders With Cc","code_information":[{"code":"546","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8566.32,"maximum":13740.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13740.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8566.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13264.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8566.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13148.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8566.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10719.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10423.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Connective Tissue Disorders Without Cc/Mcc","code_information":[{"code":"547","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6338.17,"maximum":9961.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9961.65},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6338.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9616.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6338.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9532.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6338.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7771.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7556.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Mcc","code_information":[{"code":"548","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14027.83,"maximum":23002.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23002.81},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14027.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22205.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14027.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22012.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14027.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17945.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17449.54}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis With Cc","code_information":[{"code":"549","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8944.24,"maximum":14381.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14381.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8944.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13882.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8944.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13762.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8944.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11219.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10909.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":12649.94,"10th_percentile":12649.94,"90th_percentile":12649.94,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septic Arthritis Without Cc/Mcc","code_information":[{"code":"550","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6604.39,"maximum":10413.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10413.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6604.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10052.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6604.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9964.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6604.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8123.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7899.24}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems With Mcc","code_information":[{"code":"551","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12238.0,"maximum":19967.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19967.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12238.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19275.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12238.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19107.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12238.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15577.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15146.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Medical Back Problems Without Mcc","code_information":[{"code":"552","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7216.93,"maximum":11451.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11451.97},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7216.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11054.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7216.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10958.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7216.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8934.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8687.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies With Mcc","code_information":[{"code":"553","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9570.12,"maximum":15442.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15442.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9570.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14907.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9570.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14777.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9570.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12047.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11714.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone Diseases And Arthropathies Without Mcc","code_information":[{"code":"554","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6295.32,"maximum":9888.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9888.98},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6295.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9546.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6295.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9463.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6295.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7714.95},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7501.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"555","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9749.24,"maximum":15746.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15746.6},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15200.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15068.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9749.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12284.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11945.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Of Musculoskeletal System And Connective Tissue Without Mcc","code_information":[{"code":"556","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6298.83,"maximum":9894.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9894.94},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6298.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9551.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6298.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9468.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6298.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7719.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7506.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis With Mcc","code_information":[{"code":"557","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10908.98,"maximum":17713.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17713.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10908.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17099.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10908.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16950.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10908.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13819.25},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13437.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Tendonitis, Myositis And Bursitis Without Mcc","code_information":[{"code":"558","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6738.56,"maximum":10640.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10640.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6738.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10271.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6738.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10182.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6738.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8301.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8071.85}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6619.07,"10th_percentile":6619.07,"90th_percentile":6619.07,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Mcc","code_information":[{"code":"559","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13564.22,"maximum":22216.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22216.55},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13564.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21446.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13564.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21259.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13564.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17332.38},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16853.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue With Cc","code_information":[{"code":"560","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8374.56,"maximum":13415.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13415.23},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8374.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12950.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8374.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12837.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8374.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10465.97},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10176.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":454.04,"10th_percentile":454.04,"90th_percentile":454.04,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare, Musculoskeletal System And Connective Tissue Without Cc/Mcc","code_information":[{"code":"561","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6111.28,"maximum":9576.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9576.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6111.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9244.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6111.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9164.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6111.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7471.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7264.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh With Mcc","code_information":[{"code":"562","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10472.76,"maximum":16973.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16973.64},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10472.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16385.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10472.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16242.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10472.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13242.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12875.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fracture, Sprain, Strain And Dislocation Except Femur, Hip, Pelvis And Thigh Without Mcc","code_information":[{"code":"563","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6754.72,"maximum":10668.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10668.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6754.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10298.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6754.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10208.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6754.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8322.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8092.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6194.12,"10th_percentile":6194.12,"90th_percentile":6194.12,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Mcc","code_information":[{"code":"564","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11307.26,"maximum":18388.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18388.91},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11307.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17751.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11307.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17597.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11307.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14346.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13949.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses With Cc","code_information":[{"code":"565","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7308.95,"maximum":11608.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11608.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7308.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11205.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7308.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11108.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7308.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9056.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8805.65}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Musculoskeletal System And Connective Tissue Diagnoses Without Cc/Mcc","code_information":[{"code":"566","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5727.74,"maximum":8926.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8926.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5727.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8616.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5727.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8542.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5727.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6963.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6771.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Mcc","code_information":[{"code":"570","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":21123.94,"maximum":35037.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35037.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21123.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33822.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21123.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33528.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":21123.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27334.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26578.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":24136.24,"10th_percentile":24136.24,"90th_percentile":24136.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement With Cc","code_information":[{"code":"571","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12332.13,"maximum":20127.01,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20127.01},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12332.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19429.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12332.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19260.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12332.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15702.21},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15268.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Debridement Without Cc/Mcc","code_information":[{"code":"572","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8516.45,"maximum":13655.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13655.87},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8516.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13182.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8516.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13067.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8516.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10653.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10359.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"573","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":46484.31,"maximum":78046.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78046.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46484.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":75341.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46484.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":74685.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":46484.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60888.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59205.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis With Cc","code_information":[{"code":"574","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24849.0,"maximum":41354.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41354.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24849.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39921.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24849.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39573.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24849.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32263.19},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31371.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"575","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13087.26,"maximum":21407.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21407.66},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13087.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20665.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13087.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20485.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13087.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16701.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16239.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis With Mcc","code_information":[{"code":"576","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":34892.56,"maximum":58388.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58388.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34892.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56363.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34892.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55873.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":34892.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45551.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44292.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Graft Except For Skin Ulcer Or Cellulitis Without Cc/Mcc","code_information":[{"code":"578","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11748.4,"maximum":19137.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19137.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11748.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18473.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11748.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18312.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11748.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14929.88},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14517.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Mcc","code_information":[{"code":"579","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23213.01,"maximum":38580.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38580.25},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23213.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37242.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23213.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36918.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23213.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30098.62},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29266.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures With Cc","code_information":[{"code":"580","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12602.57,"maximum":20585.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20585.66},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12602.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19872.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12602.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19699.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12602.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16060.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15615.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Skin, Subcutaneous Tissue And Breast Procedures Without Cc/Mcc","code_information":[{"code":"581","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10601.31,"maximum":17191.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17191.65},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10601.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16595.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10601.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16451.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10601.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13412.17},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13041.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy With Cc/Mcc","code_information":[{"code":"582","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13997.63,"maximum":22951.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22951.59},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13997.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22155.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13997.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21963.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13997.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17905.82},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17410.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mastectomy For Malignancy Without Cc/Mcc","code_information":[{"code":"583","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12577.28,"maximum":20542.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20542.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12577.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19830.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12577.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19658.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12577.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16026.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15583.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures With Cc/Mcc","code_information":[{"code":"584","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15501.56,"maximum":25502.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25502.16},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15501.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24618.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15501.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24403.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15501.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19895.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19345.51}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Breast Biopsy, Local Excision And Other Breast Procedures Without Cc/Mcc","code_information":[{"code":"585","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14015.19,"maximum":22981.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22981.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14015.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22184.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14015.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21991.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14015.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17929.06},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17433.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Mcc","code_information":[{"code":"592","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14058.74,"maximum":23055.23,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23055.23},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14058.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22255.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14058.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22062.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14058.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17986.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17489.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"741","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10481.89,"maximum":16989.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16989.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10481.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16400.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10481.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16257.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10481.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13254.17},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12887.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy With Cc/Mcc","code_information":[{"code":"742","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13352.78,"maximum":21857.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21857.97},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13352.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21100.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13352.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20916.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13352.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17052.63},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16581.09}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Malignancy Without Cc/Mcc","code_information":[{"code":"743","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9179.56,"maximum":14780.46,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14780.46},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9179.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14268.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9179.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14143.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9179.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11531.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11212.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption With Cc/Mcc","code_information":[{"code":"744","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14858.12,"maximum":24410.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24410.93},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14858.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23564.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14858.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23359.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14858.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19044.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18517.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization, Laparoscopy And Tubal Interruption Without Cc/Mcc","code_information":[{"code":"745","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8454.63,"maximum":13551.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13551.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8454.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13081.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8454.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12967.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8454.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10571.93},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10279.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures With Cc/Mcc","code_information":[{"code":"746","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12666.5,"maximum":20694.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20694.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12666.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19976.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12666.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19802.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12666.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16144.61},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15698.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vagina, Cervix And Vulva Procedures Without Cc/Mcc","code_information":[{"code":"747","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6503.24,"maximum":10241.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10241.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6503.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9886.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6503.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9800.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6503.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7990.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7769.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Female Reproductive System Reconstructive Procedures","code_information":[{"code":"748","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10209.34,"maximum":16526.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16526.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10209.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15953.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10209.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15815.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10209.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12893.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12537.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures With Cc/Mcc","code_information":[{"code":"749","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18500.3,"maximum":30587.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30587.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18500.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29527.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18500.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29270.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18500.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23863.27},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23203.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures Without Cc/Mcc","code_information":[{"code":"750","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10831.01,"maximum":17581.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17581.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10831.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16971.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10831.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16824.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10831.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13716.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13336.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With O.R. Procedures Except Sterilization And/Or D&C","code_information":[{"code":"768","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7991.72,"maximum":12765.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12765.97},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7991.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12323.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7991.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12216.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7991.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9959.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9684.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses With O.R. Procedures","code_information":[{"code":"769","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12334.24,"maximum":20130.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20130.59},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12334.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19432.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12334.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19263.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12334.24,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15705.0},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15270.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Abortion With D&C, Aspiration Curettage Or Hysterotomy","code_information":[{"code":"770","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7507.74,"maximum":11945.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11945.17},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7507.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11531.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7507.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11430.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7507.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9319.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9061.4}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"1 through 10","median_amount":13816.1,"10th_percentile":13816.1,"90th_percentile":13816.1},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postpartum And Post Abortion Diagnoses Without O.R. Procedures","code_information":[{"code":"776","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5063.23,"maximum":7799.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7799.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5063.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7529.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5063.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7463.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5063.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6084.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5916.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1962.24,"10th_percentile":1962.24,"90th_percentile":1962.24,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Abortion Without D&C","code_information":[{"code":"779","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6373.99,"maximum":10022.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10022.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9674.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9590.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6373.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7819.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7602.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Mcc","code_information":[{"code":"783","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17710.05,"maximum":29247.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29247.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17710.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28233.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17710.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27988.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17710.05,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22817.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22186.74}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization With Cc","code_information":[{"code":"784","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7910.94,"maximum":12628.97,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12628.97},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7910.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12191.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7910.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12085.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7910.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9852.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9580.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section With Sterilization Without Cc/Mcc","code_information":[{"code":"785","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7192.34,"maximum":11410.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11410.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7192.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11014.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7192.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10918.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7192.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8901.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8655.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":990.08,"10th_percentile":990.08,"90th_percentile":990.08,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Mcc","code_information":[{"code":"786","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12051.15,"maximum":19650.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19650.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12051.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18969.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12051.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18804.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12051.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15330.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14906.53}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section Without Sterilization With Cc","code_information":[{"code":"787","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8309.23,"maximum":13304.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13304.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12843.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12731.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8309.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10379.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10092.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":4209.13,"10th_percentile":4209.13,"90th_percentile":4209.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Cesarean Section Without Sterilization Without Cc/Mcc","code_information":[{"code":"788","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7199.36,"maximum":11422.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11422.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7199.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11026.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7199.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10930.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7199.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8911.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8664.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":16190.13,"10th_percentile":16190.13,"90th_percentile":17002.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":5729.0,"10th_percentile":5729.0,"90th_percentile":5729.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":5246.61,"10th_percentile":5246.61,"90th_percentile":5246.61,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Neonates, Died Or Transferred To Another Acute Care Facility","code_information":[{"code":"789","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13123.79,"maximum":21469.61,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21469.61},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13123.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20725.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13123.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20545.08},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13123.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16749.65},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16286.48}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":1653.6,"10th_percentile":1653.6,"90th_percentile":1653.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extreme Immaturity Or Respiratory Distress Syndrome, Neonate","code_information":[{"code":"790","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":42214.15,"maximum":70804.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70804.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42214.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":68350.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42214.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":67755.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":42214.15,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55238.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53711.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity With Major Problems","code_information":[{"code":"791","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28976.57,"maximum":48354.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48354.87},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28976.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46678.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28976.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46272.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28976.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37724.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36681.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prematurity Without Major Problems","code_information":[{"code":"792","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17668.61,"maximum":29177.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29177.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17668.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28165.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17668.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27920.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17668.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22762.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22133.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Term Neonate With Major Problems","code_information":[{"code":"793","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29753.47,"maximum":49672.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49672.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29753.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47950.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29753.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47533.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29753.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38752.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37680.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neonate With Other Significant Problems","code_information":[{"code":"794","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10831.71,"maximum":17582.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17582.4},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10831.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16972.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10831.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16825.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10831.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13717.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13337.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"1 through 10","median_amount":6686.45,"10th_percentile":6686.45,"90th_percentile":6686.45},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":2921.02,"10th_percentile":2921.02,"90th_percentile":2921.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2080.73,"10th_percentile":2080.73,"90th_percentile":2080.73,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Normal Newborn","code_information":[{"code":"795","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":1805.59,"maximum":2380.22,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2380.22},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1867.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2297.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1867.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":2277.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":1867.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1856.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":1805.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":2921.02,"10th_percentile":2921.02,"90th_percentile":2921.02,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":1698.0,"10th_percentile":1698.0,"90th_percentile":1698.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1452.61,"10th_percentile":1452.61,"90th_percentile":1715.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Mcc","code_information":[{"code":"796","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8661.86,"maximum":13902.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13902.47},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8661.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13420.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8661.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13303.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8661.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10846.1},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10546.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C With Cc","code_information":[{"code":"797","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7491.58,"maximum":11917.77,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11917.77},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7491.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11504.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7491.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11404.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7491.58,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9297.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9040.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery With Sterilization And/Or D&C Without Cc/Mcc","code_information":[{"code":"798","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7187.42,"maximum":11401.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11401.93},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7187.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11006.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7187.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10910.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7187.42,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8895.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8649.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Mcc","code_information":[{"code":"799","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32277.36,"maximum":53952.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53952.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32277.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52082.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32277.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51629.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32277.36,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42091.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40927.67}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures With Cc","code_information":[{"code":"800","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20198.81,"maximum":33468.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33468.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20198.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32308.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20198.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32027.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20198.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26110.56},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25388.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Splenic Procedures Without Cc/Mcc","code_information":[{"code":"801","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13873.3,"maximum":22740.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22740.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13873.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21952.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13873.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21761.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13873.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17741.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17250.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Mcc","code_information":[{"code":"802","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":28450.44,"maximum":47462.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47462.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28450.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45817.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28450.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45418.74},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":28450.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37028.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36004.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs With Cc","code_information":[{"code":"803","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13522.07,"maximum":22145.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22145.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13522.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21377.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13522.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21191.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13522.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17276.62},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16798.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures Of The Blood And Blood Forming Organs Without Cc/Mcc","code_information":[{"code":"804","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9989.48,"maximum":16154.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16154.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9989.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15594.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9989.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15458.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9989.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12602.66},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12254.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Mcc","code_information":[{"code":"805","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8045.11,"maximum":12856.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12856.51},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8045.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12410.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8045.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12302.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8045.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10030.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9752.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C With Cc","code_information":[{"code":"806","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5760.76,"maximum":8982.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8982.4},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5760.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8671.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5760.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8595.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5760.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7007.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6813.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":10283.1,"10th_percentile":10283.1,"90th_percentile":10283.1,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2836.43,"10th_percentile":2836.43,"90th_percentile":2836.43,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Vaginal Delivery Without Sterilization Or D&C Without Cc/Mcc","code_information":[{"code":"807","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5200.21,"maximum":8031.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8031.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5200.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7753.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5200.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7685.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5200.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6266.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6092.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":9410.88,"10th_percentile":1765.62,"90th_percentile":10976.64,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"1 through 10","median_amount":1921.8,"10th_percentile":1921.8,"90th_percentile":1921.8},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":2971.0,"10th_percentile":2971.0,"90th_percentile":4668.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"12","median_amount":2836.43,"10th_percentile":2501.2,"90th_percentile":9040.28,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"808","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15973.61,"maximum":26302.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26302.71},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15973.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25390.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15973.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25170.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15973.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20520.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19952.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"809","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9356.57,"maximum":15080.67,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15080.67},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9356.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14557.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9356.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14431.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9356.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11765.27},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11439.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Hematological And Immunological Diagnoses Except Sickle Cell Crisis And Coagulation Disorders ","code_information":[{"code":"810","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7816.11,"maximum":12468.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12468.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12035.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11931.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7816.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9727.1},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9458.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders With Mcc","code_information":[{"code":"811","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10328.76,"maximum":16729.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16729.43},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10328.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16149.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10328.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16009.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10328.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13051.56},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12690.66}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders Without Mcc","code_information":[{"code":"812","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6914.17,"maximum":10938.52,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10938.52},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6914.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10559.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6914.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10467.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6914.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8533.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8297.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coagulation Disorders","code_information":[{"code":"813","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11178.72,"maximum":18170.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18170.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11178.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17540.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11178.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17388.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11178.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14176.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13784.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses With O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures With Cc","code_information":[{"code":"821","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16189.26,"maximum":26668.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26668.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16189.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25743.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16189.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25520.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16189.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20805.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20230.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Leukemia With Major O.R. Procedures Without Cc/Mcc","code_information":[{"code":"822","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8921.76,"maximum":14343.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14343.25},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8921.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13846.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8921.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13725.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8921.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11189.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10880.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Mcc","code_information":[{"code":"823","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":32670.03,"maximum":54618.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54618.72},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32670.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52725.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32670.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":52266.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":32670.03,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42611.13},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41432.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Other Procedures With Cc","code_information":[{"code":"824","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16378.92,"maximum":26990.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26990.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16378.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26054.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16378.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25827.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16378.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21056.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20474.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Major O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Myeloproliferative Disorders Or Poorly Differentiated Neoplasms With Other Procedures Without Cc/Mcc","code_information":[{"code":"830","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11036.12,"maximum":17929.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17929.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11036.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17307.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11036.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17157.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11036.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13987.47},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13600.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Mcc","code_information":[{"code":"831","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8911.22,"maximum":14325.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14325.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8911.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13828.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8911.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13708.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8911.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11176.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10866.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures With Cc","code_information":[{"code":"832","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5533.16,"maximum":8596.42,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8596.42},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5533.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8298.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5533.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8226.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5533.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6706.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6521.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses Without O.R. Procedures Without Cc/Mcc","code_information":[{"code":"833","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4137.41,"maximum":6229.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6229.31},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4137.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6013.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4137.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5961.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4137.41,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4859.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":4725.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":2400.93,"10th_percentile":2400.93,"90th_percentile":2400.93,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Acute Leukemia With Mcc","code_information":[{"code":"834","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":39027.86,"maximum":65401.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":65401.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39027.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":63133.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39027.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62584.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":39027.86,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":51023.13},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":49612.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Cc","code_information":[{"code":"835","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15115.92,"maximum":24848.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24848.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15115.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23986.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15115.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23778.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15115.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19385.43},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18849.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia With Cc","code_information":[{"code":"841","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11924.01,"maximum":19434.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19434.87},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11924.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18761.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11924.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18597.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11924.01,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15162.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14742.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma And Non-Acute Leukemia Without Cc/Mcc","code_information":[{"code":"842","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7561.83,"maximum":12036.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12036.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7561.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11619.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7561.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11518.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7561.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9390.66},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9130.98}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Mcc","code_information":[{"code":"843","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14476.7,"maximum":23764.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23764.05},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14476.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22940.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14476.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22740.72},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14476.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18539.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18027.01}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses With Cc","code_information":[{"code":"844","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9015.89,"maximum":14502.89,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14502.89},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9015.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14000.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9015.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13878.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9015.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11314.52},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11001.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Myeloproliferative Disorders Or Poorly Differentiated Neoplastic Diagnoses Without Cc/Mcc","code_information":[{"code":"845","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6446.34,"maximum":10145.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10145.11},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6446.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9793.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6446.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9708.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6446.34,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7914.77},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7695.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Mcc","code_information":[{"code":"846","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18675.21,"maximum":30884.45,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30884.45},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18675.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29813.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18675.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29554.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18675.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24094.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23428.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis With Cc","code_information":[{"code":"847","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9653.71,"maximum":15584.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15584.59},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9653.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15044.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9653.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14913.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9653.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12158.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11822.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Chemotherapy Without Acute Leukemia As Secondary Diagnosis Without Cc/Mcc","code_information":[{"code":"848","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6430.89,"maximum":10118.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10118.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6430.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9768.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6430.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9683.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6430.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7894.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7676.03}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Radiotherapy","code_information":[{"code":"849","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19497.07,"maximum":32278.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32278.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19497.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31159.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19497.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30888.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19497.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25182.09},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24485.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Leukemia With Other Procedures","code_information":[{"code":"850","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":61292.56,"maximum":103160.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":103160.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61292.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":99584.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61292.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":98718.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":61292.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80481.39},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78255.9}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. Procedures With Mcc","code_information":[{"code":"853","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":35155.28,"maximum":58833.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":58833.54},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35155.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56793.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35155.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56300.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":35155.28,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45899.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44630.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":1247.79,"10th_percentile":1247.79,"90th_percentile":1247.79,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":20974.06,"10th_percentile":20974.06,"90th_percentile":20974.06,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Infectious And Parasitic Diseases With O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative Or Post-Traumatic Infections With O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections With Mcc","code_information":[{"code":"862","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13274.81,"maximum":21725.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21725.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13274.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20972.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13274.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20790.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13274.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16949.47},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16480.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Postoperative And Post-Traumatic Infections Without Mcc","code_information":[{"code":"863","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7474.02,"maximum":11887.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11887.98},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7474.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11475.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7474.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11376.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7474.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9274.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9018.02}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Fever And Inflammatory Conditions","code_information":[{"code":"864","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6699.93,"maximum":10575.17,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10575.17},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10208.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10119.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6699.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8250.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8022.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness With Mcc","code_information":[{"code":"865","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10989.06,"maximum":17849.25,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17849.25},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10989.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17230.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10989.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17080.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10989.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13925.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13540.14}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Viral Illness Without Mcc","code_information":[{"code":"866","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6572.78,"maximum":10359.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10359.54},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6572.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10000.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6572.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9913.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6572.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8082.06},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7858.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Mcc","code_information":[{"code":"867","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15167.9,"maximum":24936.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24936.29},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15167.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24071.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15167.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23862.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15167.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19454.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18916.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses With Cc","code_information":[{"code":"868","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7707.23,"maximum":12283.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12283.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7707.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11857.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7707.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11754.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7707.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9583.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9318.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Infectious And Parasitic Diseases Diagnoses Without Cc/Mcc","code_information":[{"code":"869","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5590.06,"maximum":8692.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8692.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5590.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8391.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5590.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8318.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5590.06,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6781.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6594.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis With Mv >96 Hours","code_information":[{"code":"870","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":49015.93,"maximum":82340.27,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82340.27},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49015.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":79485.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49015.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":78794.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":49015.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64238.27},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62461.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours With Mcc","code_information":[{"code":"871","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14109.32,"maximum":23141.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23141.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14109.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22338.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14109.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22144.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14109.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18053.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17554.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":25446.48,"10th_percentile":25446.48,"90th_percentile":25446.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":16209.13,"10th_percentile":1676.0,"90th_percentile":16728.29,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11639.48,"10th_percentile":8988.23,"90th_percentile":16243.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":5.95,"10th_percentile":5.95,"90th_percentile":5.95,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Septicemia Or Severe Sepsis Without Mv >96 Hours Without Mcc","code_information":[{"code":"872","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7652.44,"maximum":12190.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12190.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7652.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11767.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7652.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11665.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7652.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9510.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9247.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8555.72,"10th_percentile":8555.72,"90th_percentile":8555.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":7556.9,"10th_percentile":7556.9,"90th_percentile":10822.41,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Principal Diagnosis Of Mental Illness","code_information":[{"code":"876","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27613.12,"maximum":46042.55,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46042.55},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27613.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44446.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27613.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44059.86},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27613.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35920.38},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34927.1}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7116.83,"10th_percentile":7116.83,"90th_percentile":7116.83,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Depressive Neuroses","code_information":[{"code":"881","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7073.63,"maximum":11208.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11208.94},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7073.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10820.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7073.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10726.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7073.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8744.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8502.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8878.72,"10th_percentile":8878.72,"90th_percentile":8878.72,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neuroses Except Depressive","code_information":[{"code":"882","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8007.18,"maximum":12792.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12792.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8007.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12348.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8007.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12241.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8007.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9979.9},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9703.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Disorders Of Personality And Impulse Control","code_information":[{"code":"883","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14276.5,"maximum":23424.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23424.53},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14276.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22612.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14276.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22415.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14276.5,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18274.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17769.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Organic Disturbances And Intellectual Disability","code_information":[{"code":"884","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11765.96,"maximum":19166.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19166.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11765.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18502.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11765.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18341.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11765.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14953.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14539.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15829.77,"10th_percentile":15829.77,"90th_percentile":15829.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"1 through 10","median_amount":4231.25,"10th_percentile":4231.25,"90th_percentile":4231.25,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":15146.16,"10th_percentile":15146.16,"90th_percentile":15309.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":12246.9,"10th_percentile":12246.9,"90th_percentile":12246.9,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Psychoses","code_information":[{"code":"885","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10276.07,"maximum":16640.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16640.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10276.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16063.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10276.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15923.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10276.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12981.86},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12622.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":18768.57,"10th_percentile":15273.01,"90th_percentile":33791.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"1 through 10","median_amount":12251.23,"10th_percentile":12251.23,"90th_percentile":12251.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":8498.13,"10th_percentile":5496.1,"90th_percentile":17332.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":6818.0,"10th_percentile":2093.55,"90th_percentile":9423.11,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Behavioral And Developmental Disorders","code_information":[{"code":"886","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15042.16,"maximum":24723.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24723.05},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15042.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23865.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15042.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23658.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15042.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19287.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18754.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Mental Disorder Diagnoses","code_information":[{"code":"887","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7986.81,"maximum":12757.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12757.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7986.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12315.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7986.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12208.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7986.81,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9952.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9677.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence, Left Ama","code_information":[{"code":"894","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4797.7,"maximum":7349.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7349.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4797.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7094.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4797.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7032.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4797.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5733.47},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5574.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence With Rehabilitation Therapy","code_information":[{"code":"895","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10408.13,"maximum":16864.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16864.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10408.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16279.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10408.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16137.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10408.13,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13156.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12792.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alcohol, Drug Abuse Or Dependence Without Rehabilitation Therapy With Mcc","code_information":[{"code":"896","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12722.69,"maximum":20789.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20789.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20068.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19894.14},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12722.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16218.96},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15770.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Wound Debridements For Injuries Without Cc/Mcc","code_information":[{"code":"903","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8680.12,"maximum":13933.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13933.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13450.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13333.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8680.12,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10870.26},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10569.68}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries With Cc/Mcc","code_information":[{"code":"904","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26265.83,"maximum":43757.64,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43757.64},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26265.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42240.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26265.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41873.34},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26265.83,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34137.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33193.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts For Injuries Without Cc/Mcc","code_information":[{"code":"905","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10884.39,"maximum":17671.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17671.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10884.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17059.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10884.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16910.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10884.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13786.72},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13405.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hand Procedures For Injuries","code_information":[{"code":"906","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14262.45,"maximum":23400.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23400.71},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14262.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22589.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14262.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22393.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14262.45,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18256.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17751.38}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Mcc","code_information":[{"code":"907","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27433.3,"maximum":45737.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":45737.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44151.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43768.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27433.3,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35682.45},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34695.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":2907.86,"10th_percentile":2907.86,"90th_percentile":2907.86,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries With Cc","code_information":[{"code":"908","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14479.51,"maximum":23768.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23768.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14479.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22944.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14479.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22745.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14479.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18543.39},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18030.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. Procedures For Injuries Without Cc/Mcc","code_information":[{"code":"909","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9685.32,"maximum":15638.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15638.2},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9685.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15096.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9685.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14964.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9685.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12200.23},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11862.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":550.0,"10th_percentile":550.0,"90th_percentile":550.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury With Mcc","code_information":[{"code":"913","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11946.49,"maximum":19472.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19472.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11946.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18797.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11946.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18634.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11946.49,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15191.97},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14771.88}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Traumatic Injury Without Mcc","code_information":[{"code":"914","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6684.47,"maximum":10548.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10548.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6684.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10183.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6684.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10094.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6684.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8229.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8002.26}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions With Mcc","code_information":[{"code":"915","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12276.64,"maximum":20032.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20032.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12276.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19338.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12276.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19170.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12276.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15628.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15196.62}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Allergic Reactions Without Mcc","code_information":[{"code":"916","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5144.71,"maximum":7937.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7937.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5144.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7662.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5144.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7595.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5144.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6192.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6021.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs With Mcc","code_information":[{"code":"917","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11481.47,"maximum":18684.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18684.35},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11481.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18036.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11481.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17879.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11481.47,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14576.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14173.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11289.65,"10th_percentile":11289.65,"90th_percentile":11289.65,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning And Toxic Effects Of Drugs Without Mcc","code_information":[{"code":"918","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6484.98,"maximum":10210.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10210.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6484.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9856.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6484.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9770.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6484.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7965.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7745.61}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":2234.77,"10th_percentile":2234.77,"90th_percentile":2234.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Mcc","code_information":[{"code":"919","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13324.69,"maximum":21810.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21810.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13324.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21054.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13324.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20871.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13324.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17015.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16544.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment With Cc","code_information":[{"code":"920","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7504.93,"maximum":11940.4,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11940.4},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7504.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11526.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7504.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11426.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7504.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9315.38},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9057.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications Of Treatment Without Cc/Mcc","code_information":[{"code":"921","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5299.95,"maximum":8200.91,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8200.91},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5299.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7916.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5299.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7847.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5299.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6397.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6221.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5744.63,"10th_percentile":5744.63,"90th_percentile":5744.63,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses With Mcc","code_information":[{"code":"922","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12752.9,"maximum":20840.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20840.6},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12752.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20118.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12752.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19943.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12752.9,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16258.92},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15809.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Injury, Poisoning And Toxic Effect Diagnoses Without Mcc","code_information":[{"code":"923","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7613.1,"maximum":12123.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12123.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7613.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11703.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7613.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11601.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7613.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9458.5},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9196.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours With Skin Graft","code_information":[{"code":"927","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":150439.88,"maximum":254348.51,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":254348.51},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150439.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":245530.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150439.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":243395.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":150439.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":198431.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":192944.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury With Cc/Mcc","code_information":[{"code":"928","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":50848.61,"maximum":85448.38,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":85448.38},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50848.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":82486.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50848.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":81768.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":50848.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":66663.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":64819.69}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn With Skin Graft Or Inhalation Injury Without Cc/Mcc","code_information":[{"code":"929","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23088.67,"maximum":38369.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38369.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23088.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37039.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23088.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36717.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23088.67,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29934.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29106.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive Burns Or Full Thickness Burns With Mv >96 Hours Without Skin Graft","code_information":[{"code":"933","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":27818.94,"maximum":46391.6,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46391.6},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27818.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44783.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27818.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44393.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":27818.94,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36192.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35191.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Full Thickness Burn Without Skin Graft Or Inhalation Injury","code_information":[{"code":"934","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15992.57,"maximum":26334.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26334.88},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15992.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25421.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15992.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25200.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15992.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20545.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19977.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive Burns","code_information":[{"code":"935","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14934.69,"maximum":24540.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24540.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23690.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23484.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14934.69,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19145.64},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18616.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Mcc","code_information":[{"code":"939","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25952.54,"maximum":43226.32,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43226.32},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25952.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41727.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25952.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41364.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25952.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33723.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32790.75}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services With Cc","code_information":[{"code":"940","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16879.76,"maximum":27839.49,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27839.49},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16879.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26874.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16879.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26640.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16879.76,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21719.15},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21118.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures With Diagnoses Of Other Contact With Health Services Without Cc/Mcc","code_information":[{"code":"941","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14707.8,"maximum":24155.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24155.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14707.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23318.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14707.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23115.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14707.8,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18845.44},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18324.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation With Cc/Mcc","code_information":[{"code":"945","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11342.39,"maximum":18448.47,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18448.47},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11342.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17808.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11342.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17654.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11342.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14392.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13994.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Rehabilitation Without Cc/Mcc","code_information":[{"code":"946","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8519.96,"maximum":13661.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13661.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8519.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13188.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8519.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13073.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8519.96,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10658.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10363.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms With Mcc","code_information":[{"code":"947","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9381.16,"maximum":15122.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15122.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9381.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14598.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9381.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14471.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9381.16,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11797.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11471.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":1480.0,"10th_percentile":1480.0,"90th_percentile":1480.0,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Signs And Symptoms Without Mcc","code_information":[{"code":"948","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6087.39,"maximum":9536.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9536.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6087.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9205.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6087.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9125.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6087.39,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7439.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7234.12}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":21925.44,"10th_percentile":21925.44,"90th_percentile":21925.44,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare With Cc/Mcc","code_information":[{"code":"949","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8821.31,"maximum":14172.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14172.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8821.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13681.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8821.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13562.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8821.31,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11057.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10751.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Aftercare Without Cc/Mcc","code_information":[{"code":"950","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4873.57,"maximum":7477.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7477.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4873.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7218.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4873.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7155.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4873.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5833.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5672.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Factors Influencing Health Status","code_information":[{"code":"951","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4369.92,"maximum":6623.63,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6623.63},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4369.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6394.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4369.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6338.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4369.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5167.46},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5024.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Craniotomy For Multiple Significant Trauma","code_information":[{"code":"955","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":47746.61,"maximum":80187.59,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":80187.59},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47746.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":77407.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47746.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":76734.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":47746.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":62558.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":60828.95}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Limb Reattachment, Hip And Femur Procedures For Multiple Significant Trauma","code_information":[{"code":"956","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26897.33,"maximum":44828.62,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44828.62},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26897.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43274.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26897.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42898.2},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26897.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34973.32},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34006.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Mcc","code_information":[{"code":"963","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":19667.77,"maximum":32567.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32567.76},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19667.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31438.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19667.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31165.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":19667.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25407.94},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24705.35}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma With Cc","code_information":[{"code":"964","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11229.99,"maximum":18257.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18257.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11229.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17624.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11229.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17471.64},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11229.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14243.98},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13850.11}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Multiple Significant Trauma Without Cc/Mcc","code_information":[{"code":"965","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7070.82,"maximum":11204.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11204.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7070.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10815.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7070.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10721.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7070.82,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8741.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8499.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures With Mcc","code_information":[{"code":"969","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":43463.1,"maximum":72923.05,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":72923.05},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43463.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":70394.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43463.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":69782.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":43463.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56891.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55318.19}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Extensive O.R. Procedures Without Mcc","code_information":[{"code":"970","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":18990.61,"maximum":31419.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31419.35},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18990.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30330.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18990.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30066.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":18990.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24512.0},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23834.18}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Mcc","code_information":[{"code":"974","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20736.89,"maximum":34380.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34380.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20736.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33189.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20736.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32900.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20736.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26822.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26080.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition With Cc","code_information":[{"code":"975","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9560.99,"maximum":15427.34,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15427.34},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9560.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14892.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9560.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14763.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9560.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12035.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11702.92}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Major Related Condition Without Cc/Mcc","code_information":[{"code":"976","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6805.29,"maximum":10753.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10753.87},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6805.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10381.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6805.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10290.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6805.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8389.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8157.7}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hiv With Or Without Other Related Condition","code_information":[{"code":"977","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9579.95,"maximum":15459.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15459.5},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9579.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14923.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9579.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14793.78},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9579.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12060.82},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11727.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"981","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33421.64,"maximum":55893.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":55893.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33421.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53955.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33421.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53486.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33421.64,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43605.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42399.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"982","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":17733.93,"maximum":29288.11,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29288.11},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17733.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28272.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17733.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28026.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":17733.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22849.3},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22217.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"983","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12504.23,"maximum":20418.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20418.88},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12504.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19711.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12504.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19539.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12504.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15929.92},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15489.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":11033.19,"10th_percentile":11033.19,"90th_percentile":11033.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Mcc","code_information":[{"code":"987","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":24546.95,"maximum":40842.53,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40842.53},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24546.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39426.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24546.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39083.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":24546.95,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31863.55},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30982.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis With Cc","code_information":[{"code":"988","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12009.71,"maximum":19580.21,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19580.21},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12009.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18901.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12009.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18737.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12009.71,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15275.62},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14853.21}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11803.13,"10th_percentile":11803.13,"90th_percentile":11803.13,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Extensive O.R. Procedures Unrelated To Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"989","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8888.04,"maximum":14286.07,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14286.07},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8888.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13790.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8888.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13670.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8888.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11145.36},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10837.17}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers With Cc","code_information":[{"code":"593","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8797.43,"maximum":14132.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14132.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8797.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13642.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8797.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13523.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8797.43,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11025.47},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10720.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Ulcers Without Cc/Mcc","code_information":[{"code":"594","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6553.11,"maximum":10326.19,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10326.19},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6553.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9968.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6553.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9881.52},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6553.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8056.04},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7833.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders With Mcc","code_information":[{"code":"595","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15361.07,"maximum":25263.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25263.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15361.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24388.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15361.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24175.98},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15361.07,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19709.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19164.77}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Skin Disorders Without Mcc","code_information":[{"code":"596","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8068.29,"maximum":12895.82,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12895.82},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8068.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12448.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8068.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12340.5},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8068.29,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10060.76},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9782.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Mcc","code_information":[{"code":"597","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12174.78,"maximum":19860.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19860.16},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12174.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19171.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12174.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19004.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12174.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15494.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15065.58}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders With Cc","code_information":[{"code":"598","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8411.08,"maximum":13477.18,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13477.18},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8411.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13009.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8411.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12896.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8411.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10514.3},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10223.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"599","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5868.93,"maximum":9165.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9165.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5868.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8848.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5868.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8771.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5868.93,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7150.8},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6953.07}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders With Cc/Mcc","code_information":[{"code":"600","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7780.99,"maximum":12408.58,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12408.58},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7780.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11978.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7780.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11874.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7780.99,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9680.63},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9412.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Non-Malignant Breast Disorders Without Cc/Mcc","code_information":[{"code":"601","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4714.11,"maximum":7207.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7207.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4714.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6957.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4714.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6897.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4714.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5622.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5467.39}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis With Mcc","code_information":[{"code":"602","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10448.17,"maximum":16931.95,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16931.95},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10448.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16344.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10448.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16202.82},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10448.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13209.56},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12844.29}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cellulitis Without Mcc","code_information":[{"code":"603","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6581.92,"maximum":10375.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10375.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6581.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10015.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6581.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9928.26},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6581.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8094.14},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7870.32}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7575.3,"10th_percentile":7575.3,"90th_percentile":7575.3,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":12420.31,"10th_percentile":12420.31,"90th_percentile":12420.31,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":3464.99,"10th_percentile":3464.99,"90th_percentile":3464.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast With Mcc","code_information":[{"code":"604","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10805.02,"maximum":17537.13,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17537.13},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10805.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16929.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10805.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16781.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10805.02,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13681.7},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13303.37}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Trauma To The Skin, Subcutaneous Tissue And Breast Without Mcc","code_information":[{"code":"605","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6898.72,"maximum":10912.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10912.31},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6898.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10534.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6898.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10442.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6898.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8513.3},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8277.89}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Skin Disorders With Mcc","code_information":[{"code":"606","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11093.72,"maximum":18026.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18026.75},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11093.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17401.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11093.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17250.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11093.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14063.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13674.79}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"O.R. Procedures For Obesity Without Cc/Mcc","code_information":[{"code":"621","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11060.0,"maximum":17969.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17969.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11060.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17346.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11060.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17195.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11060.0,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14019.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13631.41}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Mcc","code_information":[{"code":"622","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25465.75,"maximum":42400.75,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42400.75},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25465.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40930.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25465.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40574.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25465.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33079.2},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32164.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders With Cc","code_information":[{"code":"623","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13065.48,"maximum":21370.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21370.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13065.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20629.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13065.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20450.46},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13065.48,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16672.51},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16211.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Skin Grafts And Wound Debridement For Endocrine, Nutritional And Metabolic Disorders Without Cc/Mcc","code_information":[{"code":"624","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9258.23,"maximum":14913.88,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14913.88},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9258.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14396.85},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9258.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14271.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9258.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11635.16},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11313.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Thyroid, Parathyroid And Thyroglossal Procedures With Cc","code_information":[{"code":"626","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10996.78,"maximum":17862.35,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17862.35},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10996.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17243.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10996.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17093.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10996.78,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13935.42},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13550.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures With Cc","code_information":[{"code":"629","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15769.2,"maximum":25956.04,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25956.04},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15769.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25056.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15769.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24838.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15769.2,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20249.77},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19689.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Endocrine, Nutritional And Metabolic O.R. Procedures Without Cc/Mcc","code_information":[{"code":"630","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10716.51,"maximum":17387.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17387.02},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10716.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16784.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10716.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16638.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10716.51,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13564.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13189.5}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Mcc","code_information":[{"code":"637","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10556.35,"maximum":17115.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17115.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10556.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16522.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10556.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16378.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10556.35,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13352.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12983.46}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes With Cc","code_information":[{"code":"638","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6759.63,"maximum":10676.43,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10676.43},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6759.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10306.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6759.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10216.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6759.63,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8329.28},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8098.96}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":6999.19,"10th_percentile":6999.19,"90th_percentile":6999.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Diabetes Without Cc/Mcc","code_information":[{"code":"639","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4827.91,"maximum":7400.36,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7400.36},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4827.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7143.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4827.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7081.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4827.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5773.43},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5613.78}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"1 through 10","median_amount":3470.81,"10th_percentile":3470.81,"90th_percentile":3470.81,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes With Mcc","code_information":[{"code":"640","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9846.18,"maximum":15911.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15911.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9846.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15359.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9846.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15225.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9846.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12413.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12069.82}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5831.26,"10th_percentile":5831.26,"90th_percentile":5831.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Miscellaneous Disorders Of Nutrition, Metabolism, Fluids And Electrolytes Without Mcc","code_information":[{"code":"641","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5930.75,"maximum":9270.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9270.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5930.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8949.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5930.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8871.48},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5930.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7232.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7032.59}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5860.44,"10th_percentile":5860.44,"90th_percentile":6845.27,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inborn And Other Disorders Of Metabolism","code_information":[{"code":"642","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10453.79,"maximum":16941.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16941.48},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10453.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16354.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10453.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16211.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10453.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13217.0},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12851.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Mcc","code_information":[{"code":"643","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12027.27,"maximum":19609.99,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19609.99},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12027.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18930.15},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12027.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18765.54},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12027.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15298.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14875.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":11855.48,"10th_percentile":11855.48,"90th_percentile":11855.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders With Cc","code_information":[{"code":"644","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7664.38,"maximum":12210.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12210.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7664.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11787.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7664.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11685.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7664.38,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9526.35},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9262.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endocrine Disorders Without Cc/Mcc","code_information":[{"code":"645","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5861.21,"maximum":9152.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9152.76},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8835.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8758.62},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5861.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7140.58},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6943.13}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":5774.53,"10th_percentile":5774.53,"90th_percentile":5774.53,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis With Mcc","code_information":[{"code":"650","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":33489.08,"maximum":56007.78,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":56007.78},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33489.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":54066.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33489.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":53595.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":33489.08,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":43694.81},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42486.55}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant With Hemodialysis Without Mcc","code_information":[{"code":"651","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":26495.53,"maximum":44147.2,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":44147.2},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26495.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42616.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26495.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42246.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":26495.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34441.71},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33489.31}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney Transplant","code_information":[{"code":"652","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":23149.79,"maximum":38473.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":38473.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23149.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37139.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23149.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":36816.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":23149.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":30014.97},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29184.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Mcc","code_information":[{"code":"653","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":36966.18,"maximum":61904.71,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":61904.71},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36966.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59758.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36966.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":59238.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":36966.18,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48295.34},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":46959.87}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures With Cc","code_information":[{"code":"654","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20127.87,"maximum":33348.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33348.06},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20127.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32191.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20127.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":31912.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20127.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26016.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25297.27}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Bladder Procedures Without Cc/Mcc","code_information":[{"code":"655","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15332.27,"maximum":25215.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25215.06},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15332.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24340.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15332.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24129.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15332.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19671.68},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19127.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm With Cc","code_information":[{"code":"660","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9748.54,"maximum":15745.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15745.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9748.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15199.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9748.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15067.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9748.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12283.88},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11944.2}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Ureter Procedures For Non-Neoplasm Without Cc/Mcc","code_information":[{"code":"661","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7737.44,"maximum":12334.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12334.72},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7737.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11907.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7737.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11803.56},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7737.44,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9623.01},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9356.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures With Cc","code_information":[{"code":"663","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11142.89,"maximum":18110.14,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18110.14},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11142.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17482.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11142.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17330.28},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11142.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14128.74},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13738.05}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Minor Bladder Procedures Without Cc/Mcc","code_information":[{"code":"664","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7818.22,"maximum":12471.72,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12471.72},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7818.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12039.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7818.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11934.66},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7818.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9729.89},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9460.84}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Mcc","code_information":[{"code":"665","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":22389.04,"maximum":37182.86,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37182.86},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22389.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35893.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22389.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":35581.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":22389.04,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":29008.43},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":28206.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy With Cc","code_information":[{"code":"666","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12752.19,"maximum":20839.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20839.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12752.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20116.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12752.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19942.02},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12752.19,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16257.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15808.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatectomy Without Cc/Mcc","code_information":[{"code":"667","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8234.77,"maximum":13178.16,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13178.16},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8234.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12721.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8234.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12610.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8234.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10281.02},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9996.73}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Mcc","code_information":[{"code":"668","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":20975.72,"maximum":34785.96,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":34785.96},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20975.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33580.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20975.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33288.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":20975.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27138.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26388.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures With Cc","code_information":[{"code":"669","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11366.27,"maximum":18488.98,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18488.98},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11366.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17848.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11366.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17692.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11366.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14424.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14025.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Procedures Without Cc/Mcc","code_information":[{"code":"670","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7329.32,"maximum":11642.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11642.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11238.95},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11141.22},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7329.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9083.03},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8831.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures With Cc/Mcc","code_information":[{"code":"671","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13073.21,"maximum":21383.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21383.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13073.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20642.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13073.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20463.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13073.21,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16682.73},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16221.42}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Procedures Without Cc/Mcc","code_information":[{"code":"672","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8047.22,"maximum":12860.08,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12860.08},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8047.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12414.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8047.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12306.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8047.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10032.87},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9755.44}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Mcc","code_information":[{"code":"673","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":29978.26,"maximum":50053.66,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":50053.66},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29978.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":48318.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29978.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":47898.24},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":29978.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":39049.67},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":37969.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures With Cc","code_information":[{"code":"674","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16891.7,"maximum":27859.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27859.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16891.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26893.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16891.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26660.04},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16891.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21734.95},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21133.93}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Procedures Without Cc/Mcc","code_information":[{"code":"675","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11994.26,"maximum":19554.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19554.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11994.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18876.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11994.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18711.96},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11994.26,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15255.17},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14833.33}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Mcc","code_information":[{"code":"682","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10867.53,"maximum":17643.15,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17643.15},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10867.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17031.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10867.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16883.4},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10867.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13764.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13383.8}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure With Cc","code_information":[{"code":"683","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6616.33,"maximum":10433.41,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10433.41},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6616.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10071.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6616.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9984.12},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6616.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8139.69},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7914.6}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Renal Failure Without Cc/Mcc","code_information":[{"code":"684","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":4681.1,"maximum":7151.37,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7151.37},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4681.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6903.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4681.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6843.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":4681.1,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5579.19},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":5424.91}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Mcc","code_information":[{"code":"686","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13134.32,"maximum":21487.48,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21487.48},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13134.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20742.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13134.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20562.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13134.32,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16763.59},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16300.04}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms With Cc","code_information":[{"code":"687","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7824.54,"maximum":12482.44,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12482.44},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7824.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12049.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7824.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11944.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7824.54,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9738.25},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9468.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Neoplasms Without Cc/Mcc","code_information":[{"code":"688","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6015.74,"maximum":9414.84,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9414.84},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6015.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9088.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6015.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9009.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6015.74,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7345.05},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7141.94}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections With Mcc","code_information":[{"code":"689","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8614.79,"maximum":13822.65,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13822.65},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8614.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13343.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8614.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13227.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8614.79,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10783.83},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10485.63}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":10111.88,"10th_percentile":10111.88,"90th_percentile":10111.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Infections Without Mcc","code_information":[{"code":"690","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6150.61,"maximum":9643.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9643.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6150.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9309.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6150.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9228.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6150.61,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7523.49},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7315.45}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones With Mcc","code_information":[{"code":"693","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9908.7,"maximum":16017.03,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16017.03},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9908.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15461.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9908.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15327.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9908.7,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12495.78},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12150.25}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones Without Mcc","code_information":[{"code":"694","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5955.33,"maximum":9312.39,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9312.39},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5955.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8989.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5955.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8911.38},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5955.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7265.12},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7064.22}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms With Mcc","code_information":[{"code":"695","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8498.89,"maximum":13626.09,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13626.09},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8498.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13153.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8498.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13039.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8498.89,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10630.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10336.52}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Kidney And Urinary Tract Signs And Symptoms Without Mcc","code_information":[{"code":"696","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5304.17,"maximum":8208.06,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8208.06},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5304.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7923.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5304.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7854.6},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5304.17,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6403.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6226.49}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urethral Stricture","code_information":[{"code":"697","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8035.27,"maximum":12839.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12839.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8035.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12394.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8035.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12286.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8035.27,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10017.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9740.08}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Mcc","code_information":[{"code":"698","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":12085.57,"maximum":19708.87,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19708.87},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12085.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19025.6},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12085.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18860.16},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":12085.57,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15375.99},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14950.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"1 through 10","median_amount":21780.92,"10th_percentile":21780.92,"90th_percentile":21780.92,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Kidney And Urinary Tract Diagnoses With Cc","code_information":[{"code":"699","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7594.14,"maximum":12091.7,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12091.7},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7594.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11672.5},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7594.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":11571.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7594.14,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9433.41},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9172.56}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":7469.6,"10th_percentile":7469.6,"90th_percentile":7469.6,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":14353.99,"10th_percentile":14353.99,"90th_percentile":14353.99,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures With Cc/Mcc","code_information":[{"code":"707","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14515.33,"maximum":23829.57,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23829.57},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14515.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23003.45},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14515.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":22803.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14515.33,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18590.79},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18076.71}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Male Pelvic Procedures Without Cc/Mcc","code_information":[{"code":"708","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11241.23,"maximum":18276.92,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18276.92},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17643.3},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17489.88},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11241.23,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":14258.85},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13864.57}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures With Cc/Mcc","code_information":[{"code":"709","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":16810.92,"maximum":27722.74,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":27722.74},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16810.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26761.65},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16810.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":26528.94},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":16810.92,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21628.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21030.0}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Penis Procedures Without Cc/Mcc","code_information":[{"code":"710","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10306.98,"maximum":16692.5,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16692.5},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10306.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16113.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10306.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15973.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10306.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13022.75},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12662.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures With Cc/Mcc","code_information":[{"code":"711","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15101.87,"maximum":24824.31,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24824.31},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15101.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23963.7},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15101.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23755.32},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15101.87,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19366.84},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18831.3}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Testes Procedures Without Cc/Mcc","code_information":[{"code":"712","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":8189.11,"maximum":13100.73,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13100.73},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8189.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12646.55},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8189.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12536.58},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":8189.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":10220.61},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9937.99}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy With Cc/Mcc","code_information":[{"code":"713","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":11024.88,"maximum":17910.0,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17910.0},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11024.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17289.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11024.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17138.76},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":11024.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13972.6},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13586.23}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transurethral Prostatectomy Without Cc/Mcc","code_information":[{"code":"714","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7891.98,"maximum":12596.81,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12596.81},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12160.1},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12054.36},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7891.98,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9827.48},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9555.72}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System O.R. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. 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Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System With Mcc","code_information":[{"code":"727","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10880.88,"maximum":17665.79,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17665.79},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10880.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17053.35},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10880.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16905.06},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10880.88,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13782.07},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13400.97}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inflammation Of The Male Reproductive System Without Mcc","code_information":[{"code":"728","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":6162.56,"maximum":9663.83,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9663.83},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6162.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9328.8},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6162.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9247.68},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":6162.56,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7539.29},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7330.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses With Cc/Mcc","code_information":[{"code":"729","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":7901.11,"maximum":12612.29,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12612.29},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7901.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12175.05},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7901.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12069.18},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":7901.11,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9839.56},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":9567.47}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Male Reproductive System Diagnoses Without Cc/Mcc","code_information":[{"code":"730","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":5184.75,"maximum":8005.54,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":8005.54},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5184.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7728.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5184.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":7660.8},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":5184.75,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6245.57},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":6072.86}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy With Cc/Mcc","code_information":[{"code":"734","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":15426.4,"maximum":25374.69,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":25374.69},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15426.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24495.0},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15426.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24282.0},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":15426.4,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19796.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19248.81}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Pelvic Evisceration, Radical Hysterectomy And Radical Vulvectomy Without Cc/Mcc","code_information":[{"code":"735","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":9915.72,"maximum":16028.94,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16028.94},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9915.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15473.25},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9915.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":15338.7},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":9915.72,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12505.08},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":12159.28}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Mcc","code_information":[{"code":"736","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25573.22,"maximum":42583.02,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42583.02},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25573.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41106.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25573.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40749.3},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25573.22,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33221.4},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32302.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy With Cc","code_information":[{"code":"737","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":14938.91,"maximum":24547.93,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":24547.93},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14938.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23696.9},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14938.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":23490.84},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":14938.91,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":19151.22},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":18621.64}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Ovarian Or Adnexal Malignancy Without Cc/Mcc","code_information":[{"code":"738","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":10779.73,"maximum":17494.24,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":17494.24},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16887.75},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16740.9},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":10779.73,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13648.24},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":13270.83}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Mcc","code_information":[{"code":"739","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":25631.53,"maximum":42681.9,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":42681.9},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25631.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":41202.2},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25631.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":40843.92},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":25631.53,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":33298.54},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":32377.76}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Uterine And Adnexa Procedures For Non-Ovarian And Non-Adnexal Malignancy With Cc","code_information":[{"code":"740","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","minimum":13175.77,"maximum":21557.76,"payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":21557.76},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13175.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Dean Health","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20810.4},{"payer_name":"Dean Health","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13175.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":20629.44},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"fee schedule","standard_charge_dollar":13175.77,"additional_payer_notes":"MSDRG Base Rate"},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16818.42},{"payer_name":"Unity","plan_name":"All Commercial Plans","methodology":"fee schedule","standard_charge_dollar":16353.36}]},{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Bone marrow transplant","code_information":[{"code":"009","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hyphema","code_information":[{"code":"043","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute Major Eye Infections","code_information":[{"code":"044","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Neurological eye disorders","code_information":[{"code":"045","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders of the Eye Age >17 w CC","code_information":[{"code":"046","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders of the Eye Age >17 w/o CC","code_information":[{"code":"047","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Disorders of the Eye Age 0-17","code_information":[{"code":"048","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head & Neck Procedures","code_information":[{"code":"049","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Sialoadenectomy","code_information":[{"code":"050","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Salivary Gland Procedures Except Sialoadenectomy","code_information":[{"code":"051","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Mcc","code_information":[{"code":"077","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy With Cc","code_information":[{"code":"078","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hypertensive Encephalopathy Without Cc/Mcc","code_information":[{"code":"079","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve & Oth Major Cardiothoracic Proc w Cardiac Cath","code_information":[{"code":"104","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Valve & Oth Major Cardiothoracic Proc w/o Cardiac Cath","code_information":[{"code":"105","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Coronary Bypass w PTCA","code_information":[{"code":"106","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"107","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Cardiothoracic Procedures","code_information":[{"code":"108","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"109","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Cardiovascular Procedures w CC","code_information":[{"code":"110","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Cardiovascular Procedures w/o CC","code_information":[{"code":"111","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"112","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Pacemaker Device Replacement","code_information":[{"code":"118","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vein ligation & stripping","code_information":[{"code":"119","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other circulatory system O.R. procedures","code_information":[{"code":"120","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Acute & Subacute Endocarditis","code_information":[{"code":"126","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Heart Failure & Shock","code_information":[{"code":"127","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis","code_information":[{"code":"128","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head & Neck Procedures W Cc/Mcc Or Major Device","code_information":[{"code":"129","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Head & Neck Procedures W/O Cc/Mcc","code_information":[{"code":"130","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial/Facial Procedures W Cc/Mcc","code_information":[{"code":"131","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cranial/Facial Procedures W/O Cc/Mcc","code_information":[{"code":"132","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W Cc/Mcc","code_information":[{"code":"133","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Ear, Nose, Mouth & Throat O.R. Procedures W/O Cc/Mcc","code_information":[{"code":"134","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hernia Procedures Except Inguinal & Femoral Age >17 w/o CC","code_information":[{"code":"160","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal & Femoral Hernia Procedures Age >17 w CC","code_information":[{"code":"161","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inguinal & Femoral Hernia Procedures Age >17 w/o CC","code_information":[{"code":"162","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Mouth Procedures w/o CC","code_information":[{"code":"169","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Digestive System O.R. Procedures w/o CC","code_information":[{"code":"171","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"G.I. hemorrhage w CC","code_information":[{"code":"174","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip & Femur Procedures Except Major Joint Age >17 w CC","code_information":[{"code":"210","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Hip & Femur Procedures Except Major Joint Age >17 w/o CC","code_information":[{"code":"211","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"214","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock With Mcc","code_information":[{"code":"222","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization With Ami, Hf Or Shock Without Mcc","code_information":[{"code":"223","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock With Mcc","code_information":[{"code":"224","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant With Cardiac Catheterization Without Ami, Hf Or Shock Without Mcc","code_information":[{"code":"225","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Cardiac Catheterization With Mcc","code_information":[{"code":"226","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cardiac Defibrillator Implant Without Cardiac Catheterization Without Mcc","code_information":[{"code":"227","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other cardiothoracic procedures w/o CC/MCC","code_information":[{"code":"230","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major cardiovasc procedures w MCC","code_information":[{"code":"237","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major cardiovasc procedures w/o MCC","code_information":[{"code":"238","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","code_information":[{"code":"246","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Drug-Eluting Stent Without Mcc","code_information":[{"code":"247","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent With Mcc Or 4+ Arteries Or Stents","code_information":[{"code":"248","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Percutaneous Cardiovascular Procedures With Non-Drug-Eluting Stent Without Mcc","code_information":[{"code":"249","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis With Cc/Mcc","code_information":[{"code":"294","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Deep Vein Thrombophlebitis Without Cc/Mcc","code_information":[{"code":"295","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis With Mcc","code_information":[{"code":"338","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis With Cc","code_information":[{"code":"339","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy With Complicated Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"340","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis With Mcc","code_information":[{"code":"341","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis With Cc","code_information":[{"code":"342","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Appendectomy Without Complicated Principal Diagnosis Without Cc/Mcc","code_information":[{"code":"343","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Laparoscopy & Incisional Tubal Interruption","code_information":[{"code":"361","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Endoscopic Tubal Interruption","code_information":[{"code":"362","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization & Radio-Implant, for Malignancy","code_information":[{"code":"363","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"D&C, Conization Except for Malignancy","code_information":[{"code":"364","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Female Reproductive System O.R. Procedures","code_information":[{"code":"365","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, female reproductive system w CC","code_information":[{"code":"366","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Malignancy, Female Reproductive System w/o CC","code_information":[{"code":"367","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Red Blood Cell Disorders Age 0-17","code_information":[{"code":"396","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"400","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma & non-acute leukemia w other O.R. proc w CC","code_information":[{"code":"401","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma & non-acute leukemia w CC","code_information":[{"code":"403","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Lymphoma & Non-Acute Leukemia w/o CC","code_information":[{"code":"404","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Childhood Mental Disorders","code_information":[{"code":"431","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Poisoning & toxic Effects of Drugs Age >17 w CC","code_information":[{"code":"449","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Complications of treatment w CC","code_information":[{"code":"452","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Mcc","code_information":[{"code":"453","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion With Cc","code_information":[{"code":"454","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Combined Anterior And Posterior Spinal Fusion Without Cc/Mcc","code_information":[{"code":"455","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical With Mcc","code_information":[{"code":"459","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Fusion Except Cervical Without Mcc","code_information":[{"code":"460","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"1 through 10","median_amount":25482.05,"10th_percentile":25482.05,"90th_percentile":25482.05,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major joint & limb reattachment proc of upper extremity w/o CC/MCC","code_information":[{"code":"484","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back & neck proc exc spinal fusion w CC/MCC or disc device/neurostim","code_information":[{"code":"490","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Back & neck proc exc spinal fusion w/o CC/MCC","code_information":[{"code":"491","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Arthroscopy","code_information":[{"code":"509","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Alc/Drug Abuse or Depend w/o Rehabilitation therapy w/o CC","code_information":[{"code":"523","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Transient ischemia","code_information":[{"code":"524","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other heart assist system implant","code_information":[{"code":"525","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"526","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"No Longer Valid","code_information":[{"code":"527","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Intracranial Vascular Proc w Pdx Hemorrhage","code_information":[{"code":"528","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular shunt procedures w CC","code_information":[{"code":"529","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ventricular Shunt Procedures w/o CC","code_information":[{"code":"530","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures w CC","code_information":[{"code":"531","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Spinal Procedures w/o CC","code_information":[{"code":"532","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal & Duodenal Proc Age > 17 w CC w Major Gi Dx","code_information":[{"code":"567","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Stomach, Esophageal & Duodenal Procedures Proc Age > 17 w CC w/o Major Gi Dx","code_information":[{"code":"568","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Major Small & Large Bowel Procedures w CC w Major Gi Dx","code_information":[{"code":"569","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Admit For Renal Dialysis","code_information":[{"code":"685","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones W Esw Lithotripsy W Cc/Mcc","code_information":[{"code":"691","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Urinary Stones W Esw Lithotripsy W/O Cc/Mcc","code_information":[{"code":"692","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section W Cc/Mcc","code_information":[{"code":"765","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Cesarean Section W/O Cc/Mcc","code_information":[{"code":"766","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery W Sterilization &/Or D&C","code_information":[{"code":"767","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery W Complicating Diagnoses","code_information":[{"code":"774","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Vaginal Delivery W/O Complicating Diagnoses","code_information":[{"code":"775","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ectopic Pregnancy","code_information":[{"code":"777","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Threatened Abortion","code_information":[{"code":"778","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"False Labor","code_information":[{"code":"780","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses W Medical Complications","code_information":[{"code":"781","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Other Antepartum Diagnoses W/O Medical Complications","code_information":[{"code":"782","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Mcc","code_information":[{"code":"984","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W Cc","code_information":[{"code":"985","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Prostatic O.R. Procedure Unrelated To Principal Diagnosis W/O Cc/Mcc","code_information":[{"code":"986","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Principal Diagnosis Invalid As Discharge Diagnosis","code_information":[{"code":"998","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ungroupable","code_information":[{"code":"999","type":"MS-DRG"}],"standard_charges":[{"setting":"inpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > FeeSchedule | Excess % of Charge: 74] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 11913 Days: 4 Additional Days: 1083] [Normal vag. Del. 4 day stay-Case Rate: 7580 Days: 4 Additional Days: 1083] [Normal Newborn-Case Rate: 1192] [Lower level Neonate-Case Rate: 1300] [Higher Level Neonate-Case Rate: 1625] [Severe Level Neonate-Case Rate: 1625] [Psych-Per Diem: 1625] [Rehab-Per Diem: 2166] [IP High Cost Drugs (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Total Charges > 30000 | Excess % of Charge: 85] [MSDRG Base Rate: FEE SCHEDULE] [OB Services (%BC): 85] [Nursery Level 1-Boarder (%BC): 85] [Nursery Level 2 (%BC): 85] [Nursery Level 3 (%BC): 85] [Nursery  Level 4-NICU (%BC): 85] [Rehab (%BC): 85]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[MSDRG Base Rate: FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"other","standard_charge_algorithm":"[Stop Loss: Length of Stay > FeeSchedule days | Excess % of Charge: 4162] [MSDRG Base Rate: FEE SCHEDULE] [C-Section 4 day stay-Case Rate: 5400 Days: 4 Additional Days: 1800] [Normal vag. Del. 2 day stay-Case Rate: 2800 Days: 2 Additional Days: 1800] [Normal Newborn-Case Rate: 800] [Lower level Neonate-Case Rate: 1600] [Higher Level Neonate-Case Rate: 2200] [Severe Level Neonate-Case Rate: 2200] [Rehab-Per Diem: 1540]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Inpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Ketorolac tromethamine inj","code_information":[{"code":"0764","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"1 through 10","median_amount":10141.57,"10th_percentile":10141.57,"90th_percentile":10141.57,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":82.6,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":82.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Wisconsin Physician Services","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Inj vedolizumab iv 1 mg","code_information":[{"code":"1489","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":1982.46,"10th_percentile":1982.46,"90th_percentile":1982.46,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wisconsin Physician Services","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Clinic Visits and Related Services","code_information":[{"code":"5012","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"76","median_amount":244.23,"10th_percentile":244.22,"90th_percentile":248.88,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"366","median_amount":121.71,"10th_percentile":48.69,"90th_percentile":124.19,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"1 through 10","median_amount":307.79,"10th_percentile":307.79,"90th_percentile":318.35},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Humana","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":82.6,"count":"1 through 10","median_amount":121.71,"10th_percentile":121.71,"90th_percentile":128.42},{"payer_name":"Humana","plan_name":"Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"325","median_amount":121.71,"10th_percentile":48.69,"90th_percentile":128.42,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":82.0,"count":"255","median_amount":320.29,"10th_percentile":315.68,"90th_percentile":631.12},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"16","median_amount":57.33,"10th_percentile":3.28,"90th_percentile":354.26,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wisconsin Physician Services","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"1 through 10","median_amount":48.89,"10th_percentile":48.89,"90th_percentile":48.89}]}]},{"description":"Level 1 Type A ED Visits","code_information":[{"code":"5021","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"1 through 10","median_amount":226.36,"10th_percentile":226.35,"90th_percentile":226.36,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":84.85,"10th_percentile":83.15,"90th_percentile":84.85,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":82.0,"count":"1 through 10","median_amount":272.95,"10th_percentile":233.01,"90th_percentile":398.26},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"34","median_amount":68.77,"10th_percentile":53.56,"90th_percentile":90.96,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wisconsin Physician Services","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 1 Laparoscopy and Related Services","code_information":[{"code":"5361","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"21","median_amount":18179.85,"10th_percentile":1714.18,"90th_percentile":38568.23,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"UnitedHealthCare","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":82.0,"count":"13","median_amount":3106.26,"10th_percentile":812.55,"90th_percentile":5211.01},{"payer_name":"UnitedHealthCare","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. Available, referenceable algorithm logic found here: https://www.dhs.wisconsin.gov/medicaid/index.htm]","count":"1 through 10","median_amount":132.67,"10th_percentile":132.67,"90th_percentile":186.48,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wisconsin Physician Services","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Imaging with Contrast","code_information":[{"code":"5572","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"43","median_amount":4542.11,"10th_percentile":4030.0,"90th_percentile":4611.62,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"21","median_amount":341.19,"10th_percentile":337.29,"90th_percentile":716.66,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"1 through 10","median_amount":4415.38,"10th_percentile":4415.38,"90th_percentile":4415.38},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Wisconsin Physician Services","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":85.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."}]}]},{"description":"Level 2 Minor Procedures","code_information":[{"code":"5732","type":"APC"}],"standard_charges":[{"setting":"outpatient","billing_class":"facility","payers_information":[{"payer_name":"BCBS","plan_name":"Anthem All Commercial Plans","methodology":"other","standard_charge_algorithm":"[OP Surgery  (%BC): 74] [Observation ($): 581] [Emergency Department (%BC): 74] [CT Scan OP ($): 3523] [MRI OP ($): 3523] [Laboratory Fee Schedule: FEE SCHEDULE] [Occupational Therapy ($): 205] [Physical Therapy ($): 205] [Speech Therapy ($): 205] [All Other OP (%BC): 74]","count":"1 through 10","median_amount":1203.56,"10th_percentile":1203.55,"90th_percentile":1203.56,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. 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The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"BCBS","plan_name":"Anthem Medicare Managed Care Plan","methodology":"other","standard_charge_algorithm":"[APC ($): FEE SCHEDULE]","count":"1 through 10","median_amount":563.77,"10th_percentile":563.77,"90th_percentile":563.77,"additional_payer_notes":"Contracting method is an algorithm described in the 'standard_charges|algorithm' field. The allowed amount provided accounts for the structural rates, conditions, and utilization elements inherent in the payer's algorithm."},{"payer_name":"Cigna","plan_name":"All Commercial Plans","methodology":"percent of total billed charges","standard_charge_percentage":90.0,"count":"0","additional_payer_notes":"No services performed during 15-month lookback period."},{"payer_name":"Dean Health Plan","plan_name":"Medicaid Managed Care Plan","methodology":"other","standard_charge_algorithm":"[Outpatient Services: Payer leverages state specific Medicaid payment methodology. 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